Basic Information
| Provider Information | |||||||||
| NPI: | 1790721439 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHAEFER | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3900 E. MEXICO AVE., SUITE 210 | ||||||||
| Address2: | CENTERPOINT 1 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802103940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036913733 | ||||||||
| FaxNumber: | 3036911142 | ||||||||
| Practice Location | |||||||||
| Address1: | 3900 E. MEXICO AVE., SUITE 210 | ||||||||
| Address2: | CENTERPOINT 1 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802103940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036913733 | ||||||||
| FaxNumber: | 3036911142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 06/06/2013 | ||||||||
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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 | 208100000X | 070009821 | IL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 08220357 | 01 | IL | BCBS IL GRP# | OTHER | 900068033 | 01 | IL | TAX ID# | OTHER |