Provider Demographics
NPI:1154535375
Name:SCHAEFER, MARY ALICE (DO)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ALICE
Last Name:SCHAEFER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7961 VANZYVERDEN RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305
Mailing Address - Country:US
Mailing Address - Phone:256-509-0590
Mailing Address - Fax:
Practice Address - Street 1:7961 VAN ZYVERDEN RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-9124
Practice Address - Country:US
Practice Address - Phone:256-509-0590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO451208000000X
OH340070405208000000X
MSMS19178208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1154535375OtherNPI
MS06389899Medicaid