Basic Information
| Provider Information | |||||||||
| NPI: | 1811199235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHMIDT | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | SUZANNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 COMMONS WAY STE B | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599011915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067525170 | ||||||||
| FaxNumber: | 4067525210 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 COMMONS WAY STE B | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599011915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067525170 | ||||||||
| FaxNumber: | 4067525210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2007 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 13123 | NV | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 2086S0120X | 54809 | MT | N | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 207T00000X | 54809 | MT | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 207T0000X | 05 | NV | MEDICAID | 13123NV | 01 | NV | BLUE CROSS BLUE SHIELD | OTHER | 449672 | 05 | AZ | MEDICAID |