MEDICARE: MRS. JEANNIE M WASCHOW DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	016004344	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00384162	OTHER	IL	MEDICARE RAILROAD

General Provider Information

NPI Number	:	1497739700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JEANNIE M WASCHOW DPM

Provider Business Mailing Address
First Line	:	325 E H ST
Second Line	:
City	:	IRON MOUNTAIN
State	:	MI
Zip	:	49801-4792
Country	:	US
Telephone Number	:	906-774-3300
Fax Number	:	906-779-3144

Provider Business Practice Location Address
First Line	:	325 E H ST
Second Line	:
City	:	IRON MOUNTAIN
State	:	MI
Zip	:	49801-4792
Country	:	US
Telephone Number	:	906-774-3300
Fax Number	:	906-779-3144

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	12/21/2018

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