Basic Information
| Provider Information | |||||||||
| NPI: | 1649329871 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHNEIDER | ||||||||
| FirstName: | GERALD | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34040 HIGH DR | ||||||||
| Address2: | |||||||||
| City: | EAST TROY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627678000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 248 MCHENRY ST | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531051828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7677678261 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 213E00000X | 577 | WI | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 43204100 | 05 | WI | MEDICAID |