Provider Demographics
NPI:1699760009
Name:SCHRAGE, MARYANNE E (PAC)
Entity type:Individual
Prefix:
First Name:MARYANNE
Middle Name:E
Last Name:SCHRAGE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N WALL ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2942
Mailing Address - Country:US
Mailing Address - Phone:815-937-1237
Mailing Address - Fax:815-933-0662
Practice Address - Street 1:500 N WALL ST
Practice Address - Street 2:SUITE 200
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2942
Practice Address - Country:US
Practice Address - Phone:815-937-1237
Practice Address - Fax:815-933-0662
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001161363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK06500Medicare ID - Type Unspecified
S63845Medicare UPIN