Basic Information
| Provider Information | |||||||||
| NPI: | 1205811932 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODENBERG | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 CHILDRENS DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143556000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5680 VENTURE DR | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430172190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143556000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 02/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 35083261 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 35083261 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 35083261 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 35083261 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | 35083261 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 2080S0010X | 35083261 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2464391 | 05 | OH | MEDICAID |