Provider Demographics
NPI:1225039597
Name:RODIN, PETER J (DO)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:RODIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15200 KERCHEVAL AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE PARK
Practice Address - State:MI
Practice Address - Zip Code:48230-1356
Practice Address - Country:US
Practice Address - Phone:313-417-6100
Practice Address - Fax:313-417-6107
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101008434207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2907618Medicaid
MIB48774Medicare UPIN
MI2907618Medicaid