Healthcare Provider Details

I. General information

NPI: 1740209683
Provider Name (Legal Business Name): WALTER L. SCHMALSTIEG JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 COPPER CV
OOLTEWAH TN
37363-3002
US

IV. Provider business mailing address

2615 COPPER CV
OOLTEWAH TN
37363-3002
US

V. Phone/Fax

Practice location:
  • Phone: 704-609-6885
  • Fax:
Mailing address:
  • Phone: 704-609-6885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number9600042
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1740209683
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
IdentifierN0004D
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: