Basic Information
| Provider Information | |||||||||
| NPI: | 1366618571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHMIDTKE | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30516 | ||||||||
| Address2: | DEPT 6063 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489098016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164597101 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 LEFFINGWELL AVE NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495256406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164597101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2008 | ||||||||
| LastUpdateDate: | 09/12/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5201003841 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.