Provider Demographics
NPI:1427034180
Name:SCHULTHEIS, MARK (PT, SCSC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SCHULTHEIS
Suffix:
Gender:M
Credentials:PT, SCSC
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 8467
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-8467
Mailing Address - Country:US
Mailing Address - Phone:307-733-5577
Mailing Address - Fax:307-733-5505
Practice Address - Street 1:1090 S HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83002
Practice Address - Country:US
Practice Address - Phone:307-733-5577
Practice Address - Fax:307-733-5505
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5223225100000X
WY0635225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000481085Medicare ID - Type Unspecified
WIS75620Medicare UPIN