Provider Demographics
NPI:1639182660
Name:SCHROETER, KEN A (DO)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:A
Last Name:SCHROETER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CARRIAGE LN
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-4619
Mailing Address - Country:US
Mailing Address - Phone:603-540-2890
Mailing Address - Fax:
Practice Address - Street 1:3 CARRIAGE LN
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-4619
Practice Address - Country:US
Practice Address - Phone:603-540-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT03200005222080N0001X
NH10884207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1011154Medicaid
NY02623710Medicaid
NY02623710Medicaid
VT1011154Medicaid