Provider Demographics
NPI:1508850462
Name:SCHNIDMAN, JACQUELYN C (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:C
Last Name:SCHNIDMAN
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 1:4217 BAYLESS AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-7513
Mailing Address - Country:US
Mailing Address - Phone:314-638-7330
Mailing Address - Fax:314-638-3614
Practice Address - Street 1:4217 BAYLESS AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-7513
Practice Address - Country:US
Practice Address - Phone:314-638-7330
Practice Address - Fax:314-638-3614
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9A43208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201779402Medicaid