Provider Demographics
NPI:1275829178
Name:SCHULTHEIS, MARTINE A (MD)
Entity Type:Individual
Prefix:
First Name:MARTINE
Middle Name:A
Last Name:SCHULTHEIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARTINE
Other - Middle Name:A
Other - Last Name:SCHULTHEIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:621 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5077
Mailing Address - Country:US
Mailing Address - Phone:815-397-3350
Mailing Address - Fax:
Practice Address - Street 1:621 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5077
Practice Address - Country:US
Practice Address - Phone:815-397-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-136146207Q00000X
IL125059864390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program