Provider Demographics
NPI:1194861682
Name:SCHROEDER, KELLY A (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:SCHROEDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636930
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:513-981-5015
Mailing Address - Fax:
Practice Address - Street 1:750 W HIGH ST
Practice Address - Street 2:SUITE # 250
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-2969
Practice Address - Country:US
Practice Address - Phone:419-227-7399
Practice Address - Fax:419-229-0123
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH80801207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2317157Medicaid
OH2317157Medicaid
OHSC4080564Medicare PIN