Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XS0106X | Orthopaedic Hand Surgeon | 024075 | GA |
NPI | 1205857307 |
---|---|
Provider Name | Dr. Jim W Roderique |
First Address | Atlanta, GA 30309-3821 |
Second Address | Atlanta, GA 30309-3821 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00257408B | (05) | GA |
D41811 | (02) | GA |