Provider Demographics
NPI:1912950171
Name:KEVIN R. SCHROEDER, DPM
Entity Type:Organization
Organization Name:KEVIN R. SCHROEDER, DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:SCHROEDER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:937-427-1175
Mailing Address - Street 1:3121 EVELYN DR
Mailing Address - Street 2:STE 120
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-4309
Mailing Address - Country:US
Mailing Address - Phone:937-427-1175
Mailing Address - Fax:937-427-9494
Practice Address - Street 1:3121 EVELYN DR
Practice Address - Street 2:STE 120
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45434-4309
Practice Address - Country:US
Practice Address - Phone:937-427-1175
Practice Address - Fax:937-427-9494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0752690Medicaid
OH5033000001Medicare NSC
OH0752690Medicaid
OHDG1728Medicare PIN