Basic Information
Provider Information | |||||||||
NPI: | 1013090828 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SCHULTZ | ||||||||
FirstName: | GREGORY | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2315 8TH ST | ||||||||
Address2: |   | ||||||||
City: | LEWISTON | ||||||||
State: | ID | ||||||||
PostalCode: | 835017301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2087461383 | ||||||||
FaxNumber: | 2087466348 | ||||||||
Practice Location | |||||||||
Address1: | 2315 8TH ST | ||||||||
Address2: |   | ||||||||
City: | LEWISTON | ||||||||
State: | ID | ||||||||
PostalCode: | 835017301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2087461383 | ||||||||
FaxNumber: | 2087466348 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2006 | ||||||||
LastUpdateDate: | 03/07/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | M6210 | ID | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | MD00040525 | WA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 1013090828 | 01 | ID | REGENCE BLUE CROSS | OTHER | 1127194 | 01 | ID | DMERC | OTHER | 1000325 | 05 | WA |   | MEDICAID | 841377860 | 01 | ID | MISCELLANEOUS INSURANCE | OTHER | 0210278 | 01 | WA | LABOR & INDUSTRIES | OTHER | 1013090828 | 05 | ID |   | MEDICAID | DF391 | 01 | ID | BLUE CROSS | OTHER |