Provider Demographics
NPI:1427101286
Name:SCHROECKENSTEIN, MARK D (PT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:D
Last Name:SCHROECKENSTEIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 DIFFLEY RD
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1778
Mailing Address - Country:US
Mailing Address - Phone:952-835-4512
Mailing Address - Fax:877-609-0123
Practice Address - Street 1:1012 DIFFLEY RD
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1778
Practice Address - Country:US
Practice Address - Phone:952-835-4512
Practice Address - Fax:877-609-0123
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT32436225100000X
MN9478225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA056674Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER