Healthcare Provider Details

I. General information

NPI: 1780793927
Provider Name (Legal Business Name): MARK J SCHMIDT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 09/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 CAMPUS DR SUITE# 400
PLYMOUTH MN
55441-2649
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 763-577-7400
  • Fax:
Mailing address:
  • Phone: 612-262-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0222477
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: