Provider Demographics
NPI:1891896205
Name:SCHODROF, MARK C (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:SCHODROF
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 S OBRIEN ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2440
Practice Address - Country:US
Practice Address - Phone:812-522-9574
Practice Address - Fax:812-522-2576
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013101225100000X
IN05010558A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201038240Medicaid
ILP00943146OtherMEDICARE RAILROAD
IL211585006Medicare PIN
ILK34940Medicare PIN
IN201038240Medicaid
ILK27475Medicare PIN
ILP00943146OtherMEDICARE RAILROAD
IL216859008Medicare PIN