1104988112 NPI number — MRS. KARENA DIANE SCHROEDER DPT

Table of content: MARCO GOMEZ (NPI 1487239778)

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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