Basic Information
| Provider Information | |||||||||
| NPI: | 1770535809 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STOUTAMYER STRATOS SCHROEDER WHALEY & RIZZO MDS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 40TH ST WEST | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417495464 | ||||||||
| FaxNumber: | 9417471815 | ||||||||
| Practice Location | |||||||||
| Address1: | 2020 59TH ST WEST | ||||||||
| Address2: | BLAKE MEDICAL CENTER | ||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417926611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 01/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | SCHROEDER | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9417495464 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 043629100 | 05 | FL | MEDICAID |