Provider Demographics
NPI:1063488435
Name:SCHWALLIE, ROBERT BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:BRUCE
Last Name:SCHWALLIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:B
Other - Last Name:SCHWALLIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 632745
Mailing Address - Street 2:CINCINNATI
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2745
Mailing Address - Country:US
Mailing Address - Phone:513-559-2898
Mailing Address - Fax:513-475-5415
Practice Address - Street 1:1140 MONROE AVE NW
Practice Address - Street 2:SUITE 150
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1055
Practice Address - Country:US
Practice Address - Phone:616-459-1560
Practice Address - Fax:616-459-1560
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35045428207P00000X
AZ35510207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00126487OtherMEDICARE RAILROAD
OHP00172166OtherMEDICARE RAILROAD
OH0515811Medicaid
OH000000317075OtherANTHEM
OH000000319946OtherANTHEM
KY863392Medicaid
OHP00172166OtherMEDICARE RAILROAD
KY863392Medicaid
OHP00302795Medicare PIN
OH0515811Medicaid
OH4128403Medicare PIN