Basic Information
Provider Information | |||||||||
NPI: | 1356333249 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROOF | ||||||||
FirstName: | RODNEY | ||||||||
MiddleName: | W | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4685 FOREST AVE STE C | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452123359 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5132467000 | ||||||||
FaxNumber: | 5132467852 | ||||||||
Practice Location | |||||||||
Address1: | 8245 NORTHCREEK DR | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452362283 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5132467000 | ||||||||
FaxNumber: | 5132465284 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2005 | ||||||||
LastUpdateDate: | 12/29/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 3134 | OH | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
ID Information
ID | Type | State | Issuer | Description | 000000367060 | 01 | OH | ANTHEM | OTHER | 4139962 | 01 | OH | MEDICARE | OTHER | 2145191 | 05 | OH |   | MEDICAID | 480028277 | 01 | OH | RAIL ROAD MEDICARE | OTHER | 310817854026 | 01 | OH | CARE SOURCE | OTHER | 294797 | 01 | OH | AMERIGROUP | OTHER |