Basic Information
| Provider Information | |||||||||
| NPI: | 1174702419 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHULTZ | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 S GIBSON ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544511622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157488100 | ||||||||
| FaxNumber: | 7157488199 | ||||||||
| Practice Location | |||||||||
| Address1: | 619 BRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | PRENTICE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545561131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157488100 | ||||||||
| FaxNumber: | 7157488199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2007 | ||||||||
| LastUpdateDate: | 11/02/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2143-024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40180000 | 05 | WI | MEDICAID |