Basic Information
| Provider Information | |||||||||
| NPI: | 1861774291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHICKER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30544 HIGHWAY 200 STE 102 | ||||||||
| Address2: | |||||||||
| City: | PONDERAY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838525005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082659817 | ||||||||
| FaxNumber: | 5305418723 | ||||||||
| Practice Location | |||||||||
| Address1: | 30544 HIGHWAY 200 STE 102 | ||||||||
| Address2: | |||||||||
| City: | PONDERAY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082659817 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2011 | ||||||||
| LastUpdateDate: | 07/19/2019 | ||||||||
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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 | 207XP3100X | OP60637340 | WA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 207XP3100X | O0947 | ID | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 207XX0005X | OP60637340 | WA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0005X | O0947 | ID | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8502734 | 05 | WA | MEDICAID | 807920700 | 05 | ID | MEDICAID |