=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861774291
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL DAVID SCHICKER DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2011
-----------------------------------------------------
Last Update Date | 09/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30544 HIGHWAY 200 STE 102
-----------------------------------------------------
City | PONDERAY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-265-9817
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30544 HIGHWAY 200 STE 102
-----------------------------------------------------
City | PONDERAY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83852-5005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-265-9817
-----------------------------------------------------
Fax | 530-541-8723
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | O0947
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207XP3100X
-----------------------------------------------------
Taxonomy Name | Pediatric Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | O0947
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207XP3100X
-----------------------------------------------------
Taxonomy Name | Pediatric Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | OP60637340
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | OP60637340
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------