1336336882 NPI number — MRS. PAMELA MICHELLE RODGERS NP-C

Table of content: MRS. PAMELA MICHELLE RODGERS NP-C (NPI 1336336882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336336882 NPI number — MRS. PAMELA MICHELLE RODGERS NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RODGERS
Provider First Name:
PAMELA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336336882
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 REID PKWY
Provider Second Line Business Mailing Address:
MEDICAL STAFF SERVICES
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47374-1157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-935-8581
Provider Business Mailing Address Fax Number:
765-935-1171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1485 CHESTER BLVD
Provider Second Line Business Practice Location Address:
REID PEDIATRIC & INTERNAL MEDICINE
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47374-1919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-966-5527
Provider Business Practice Location Address Fax Number:
765-966-5528
Provider Enumeration Date:
09/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  71002527A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200877930 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000855986 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 0100846 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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