Basic Information
| Provider Information | |||||||||
| NPI: | 1821098872 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHULTZ | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2955 XENIUM LN N | ||||||||
| Address2: | #40 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554412666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633982203 | ||||||||
| FaxNumber: | 7636949000 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 OAKDALE AVE N | ||||||||
| Address2: | |||||||||
| City: | ROBBINSDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554222926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635592171 | ||||||||
| FaxNumber: | 7636949000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 03/21/2019 | ||||||||
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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 | 2085B0100X | 38326 | MN | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0904X | 38326 | MN | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0204X | 38326 | MN | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 38328 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 777025100 | 05 | MN | MEDICAID |