Basic Information
Provider Information | |||||||||
NPI: | 1225023526 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SCHRADER | ||||||||
FirstName: | AGNES | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JOHENNING | ||||||||
OtherFirstName: | AGNES | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 9011 N MERIDIAN ST | ||||||||
Address2: | SUITE 225 | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462605378 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3175642134 | ||||||||
FaxNumber: | 3175744737 | ||||||||
Practice Location | |||||||||
Address1: | 165 SHERIDAN RD | ||||||||
Address2: |   | ||||||||
City: | NOBLESVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 460601310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3177730363 | ||||||||
FaxNumber: | 3177708910 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2005 | ||||||||
LastUpdateDate: | 03/06/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 01043194A | IN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 200000930 | 05 | IN |   | MEDICAID |