Basic Information
| Provider Information | |||||||||
| NPI: | 1952920985 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHROEDER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JACOB | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 E FOUNTAIN CIR | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571037279 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 915 OLENTANGY RIVER RD # 2140 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432123153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142938566 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2020 | ||||||||
| LastUpdateDate: | 04/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | OH | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.