Basic Information
| Provider Information | |||||||||
| NPI: | 1033119110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWAN | ||||||||
| FirstName: | RODNEY | ||||||||
| MiddleName: | O | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 W ICE LAKE RD | ||||||||
| Address2: | |||||||||
| City: | IRON RIVER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499359526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062656121 | ||||||||
| FaxNumber: | 9062654245 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 W ICE LAKE RD | ||||||||
| Address2: | |||||||||
| City: | IRON RIVER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499359526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062656121 | ||||||||
| FaxNumber: | 9062654245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 09/10/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 036-074809 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1615125 | 01 | IL | BLUE SHIELD GROUP # | OTHER | 1033119110 | 05 | MI | MEDICAID | 0607120001 | 01 | IL | CIGNA GROUP # | OTHER |