Provider Demographics
NPI:1457467995
Name:STUCKEY SCHROCK, KIMBERLY SUE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:SUE
Last Name:STUCKEY SCHROCK
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 1:2016 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-5236
Mailing Address - Country:US
Mailing Address - Phone:574-533-7600
Mailing Address - Fax:574-533-7666
Practice Address - Street 1:2016 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5236
Practice Address - Country:US
Practice Address - Phone:574-533-7600
Practice Address - Fax:574-533-7666
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060332A207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200526460Medicaid
IN145760FMedicare ID - Type Unspecified
IN200526460Medicaid