Provider Demographics
NPI:1457538654
Name:CAPE COUNTY OTOLARYNGOLOGY HEAD & NECK SURGERY INC
Entity type:Organization
Organization Name:CAPE COUNTY OTOLARYNGOLOGY HEAD & NECK SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:A
Authorized Official - Last Name:SCHROEDER JR
Authorized Official - Suffix:
Authorized Official - Credentials:DO, MD
Authorized Official - Phone:573-334-5007
Mailing Address - Street 1:3203 BLATTNER DR
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6360
Mailing Address - Country:US
Mailing Address - Phone:573-334-5007
Mailing Address - Fax:573-334-6369
Practice Address - Street 1:3203 BLATTNER DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6360
Practice Address - Country:US
Practice Address - Phone:573-334-5007
Practice Address - Fax:573-334-6369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9980207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26757OtherBLUE CROSS BLUE SHIELD
MO119051OtherHEALTH LINK
MO242087112Medicaid
MO242087112Medicaid
MO000005606Medicare PIN