Provider Demographics
NPI:1073513313
Name:SCHULTZ, STANTON G (MD)
Entity Type:Individual
Prefix:DR
First Name:STANTON
Middle Name:G
Last Name:SCHULTZ
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:P.O. BOX 1704
Mailing Address - Street 2:416 NORTH 12TH STREET
Mailing Address - City:MT. VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-0034
Mailing Address - Country:US
Mailing Address - Phone:618-244-4850
Mailing Address - Fax:618-244-7985
Practice Address - Street 1:416 NORTH 12TH STREET
Practice Address - Street 2:SOUTHERN ILLINOIS CONSULTANTS FOR KIDNEY DISEASE, S.C.
Practice Address - City:MT. VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-4314
Practice Address - Country:US
Practice Address - Phone:618-244-4850
Practice Address - Fax:618-244-7985
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN1027161207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100246480Medicaid
IN390004295OtherRAILROAD MEDICARE
IN637060CMedicare ID - Type Unspecified
IN100246480Medicaid