=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467899278
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA RAE SCHAEFER M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2013
-----------------------------------------------------
Last Update Date | 11/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 530 NE GLEN OAK AVE
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61637-1505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-655-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 OAKWOOD RD
-----------------------------------------------------
City | EAST PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61611-1853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-740-4272
-----------------------------------------------------
Fax | 515-282-2332
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | R-9725
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | A153355
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 036-149534
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------