Basic Information
Provider Information | |||||||||
NPI: | 1881682789 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROEDIGER | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | H | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 301C US ROUTE 1 | ||||||||
Address2: |   | ||||||||
City: | SCARBOROUGH | ||||||||
State: | ME | ||||||||
PostalCode: | 040749701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2073968600 | ||||||||
FaxNumber: | 2073968632 | ||||||||
Practice Location | |||||||||
Address1: | 1250 FOREST AVE | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041031897 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077975753 | ||||||||
FaxNumber: | 2077979571 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2005 | ||||||||
LastUpdateDate: | 04/03/2012 | ||||||||
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 | 207Y00000X | MD8727 | ME | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology |   |
ID Information
ID | Type | State | Issuer | Description | B86271 | 01 | ME | HARVARD PILGRIM | OTHER | 302230099 | 05 | ME |   | MEDICAID | 1044199 | 01 | ME | AETNA | OTHER | 040512 | 01 | ME | ANTHEM | OTHER |