Basic Information
| Provider Information | |||||||||
| NPI: | 1629016977 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHOTTLER | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 WESTGATE DR | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551141065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513121500 | ||||||||
| FaxNumber: | 6513121593 | ||||||||
| Practice Location | |||||||||
| Address1: | 6565 FRANCE AVE S | ||||||||
| Address2: | SUITE 375 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513121700 | ||||||||
| FaxNumber: | 6513121570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 08/31/2016 | ||||||||
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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 | 208C00000X | 15370 | MN | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 556873100 | 05 | MN | MEDICAID |