Provider Demographics
NPI:1952366395
Name:SCHROEDER, STEPHAN D (MD)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:D
Last Name:SCHROEDER
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 1:300 W 5TH ST
Mailing Address - Street 2:PO BOX 287
Mailing Address - City:MILLER
Mailing Address - State:SD
Mailing Address - Zip Code:57362-1238
Mailing Address - Country:US
Mailing Address - Phone:605-853-0158
Mailing Address - Fax:605-853-3885
Practice Address - Street 1:300 W 5TH ST
Practice Address - Street 2:
Practice Address - City:MILLER
Practice Address - State:SD
Practice Address - Zip Code:57362-1238
Practice Address - Country:US
Practice Address - Phone:605-853-0158
Practice Address - Fax:605-853-3885
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2523204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5600360Medicaid
SD5600360Medicaid