Provider Demographics
NPI:1801895032
Name:SCHONDELMEYER, RAYMOND WADE (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:WADE
Last Name:SCHONDELMEYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 KEENE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6625
Mailing Address - Country:US
Mailing Address - Phone:573-876-1682
Mailing Address - Fax:573-874-0665
Practice Address - Street 1:401 KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6625
Practice Address - Country:US
Practice Address - Phone:573-876-1682
Practice Address - Fax:573-874-0665
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4E43207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202147831Medicaid
0963Medicare PIN
MO202147831Medicaid