Basic Information
| Provider Information | |||||||||
| NPI: | 1962401182 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHULTZ | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23625 COMMERCE PARK | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162555725 | ||||||||
| FaxNumber: | 8669049272 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 BELLEFONTAINE AVENUE | ||||||||
| Address2: | LIMA MEMORIAL HEALTH SYSTEM | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192283335 | ||||||||
| FaxNumber: | 4192265064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 08/31/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 5101015199 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 34 004758S | OH | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 34-004758 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | DS015199 | 01 | MI | BC/BS INDIVIDUAL PIN NO | OTHER | 300129241 | 01 | MI | RR MDCR INDIVIDUAL PIN NO | OTHER | 114370467 | 05 | MI | MEDICAID | 64867591 | 05 | KY | MEDICAID | 10814679 | 01 | MI | CAQH | OTHER |