Provider Demographics
NPI:1215414446
Name:SCHAFFER, EMILY (PA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:SCHAFFER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 E SUPERIOR ST STE 306
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2595
Mailing Address - Country:US
Mailing Address - Phone:312-754-9404
Mailing Address - Fax:
Practice Address - Street 1:3665 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613
Practice Address - Country:US
Practice Address - Phone:773-496-4433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006753363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1215414446Medicaid