Provider Demographics
NPI:1982021192
Name:SCHMIDT, ETHAN THOMAS (MT-BC)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:THOMAS
Last Name:SCHMIDT
Suffix:
Gender:M
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 402
Mailing Address - Street 2:
Mailing Address - City:FLOYDS KNOBS
Mailing Address - State:IN
Mailing Address - Zip Code:47119-0402
Mailing Address - Country:US
Mailing Address - Phone:502-974-8525
Mailing Address - Fax:
Practice Address - Street 1:1021 WEST ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4856
Practice Address - Country:US
Practice Address - Phone:502-974-8525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11201171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor