Provider Demographics
NPI:1538109855
Name:SCHMIDT, ROY A (M D)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:A
Last Name:SCHMIDT
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 STONEBRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2042
Mailing Address - Country:US
Mailing Address - Phone:731-660-2056
Mailing Address - Fax:731-661-9092
Practice Address - Street 1:15 STONEBRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2042
Practice Address - Country:US
Practice Address - Phone:731-660-2056
Practice Address - Fax:731-661-9092
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD22099207L00000X, 207LP2900X
TN22099174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3380640Medicaid
KY030670000OtherBLACK LUNG
KY000000378004OtherANTHEM
KYC20829OtherCUMBERLAND HEALTHCARE INC
KY50007501OtherPASSPORT HEALTH PLAN
KY64095367Medicaid
KY0736521Medicare ID - Type Unspecified