Healthcare Provider Details

I. General information

NPI: 1306830849
Provider Name (Legal Business Name): JOHN WILLIAM SCHRADER HSD, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E. 17TH STREET, ASSEMBLY HALL SPORTS MEDICINE DEPARTMENT
BLOOMINGTON IN
47408
US

IV. Provider business mailing address

2602 N BROWNCLIFF LN
BLOOMINGTON IN
47408-1310
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-4509
  • Fax: 812-855-1810
Mailing address:
  • Phone: 812-856-4905
  • Fax: 812-856-2596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000281A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: