Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207X00000X | Orthopaedic Surgeon | 112519 | MO |
NPI | 1003812645 |
---|---|
Provider Name | Dr. Edwin Roeder |
First Address | Springfield, MO 65803-4306 |
Second Address | West Plains, MO 65775 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2005 |
Last Update Date | 29/08/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003812645 | (05) | MO |
244688917 | (05) | MO |
G36861 | (02) | |
P00061886 | RR MEDICARE (01) |