Provider Demographics
NPI:1215517503
Name:BAILEY, RODERICK THOMAS
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:THOMAS
Last Name:BAILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 GOOSEDOWN CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-3170
Mailing Address - Country:US
Mailing Address - Phone:191-238-6911
Mailing Address - Fax:
Practice Address - Street 1:429 GOOSEDOWN CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-3170
Practice Address - Country:US
Practice Address - Phone:191-238-6911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-11
Last Update Date:2021-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC251S0000XMedicaid