1104988112 NPI number — MRS. KARENA DIANE SCHROEDER DPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104988112 NPI number — MRS. KARENA DIANE SCHROEDER DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCHROEDER
Provider First Name:
KARENA
Provider Middle Name:
DIANE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUNYON
Provider Other First Name:
KARENA
Provider Other Middle Name:
DIANE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104988112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4251 LAHMEYER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46815-5676
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-432-4700
Provider Business Mailing Address Fax Number:
260-459-9262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3534 BROOKLYN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-478-5230
Provider Business Practice Location Address Fax Number:
260-478-5235
Provider Enumeration Date:
12/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  05008969A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000482874 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200838660 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100257920 . This is a "MEDICAID - GROUP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 1424 . This is a "PHP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 35179001202 . This is a "CARESOURCE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 4423623 . This is a "AETNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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