Provider Demographics
NPI:1528083078
Name:WARREN, RODERICK (MD)
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:
Last Name:WARREN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 RAVENHILL DR
Mailing Address - Street 2:
Mailing Address - City:ATCHISON
Mailing Address - State:KS
Mailing Address - Zip Code:66002-9204
Mailing Address - Country:US
Mailing Address - Phone:913-674-2340
Mailing Address - Fax:913-674-2039
Practice Address - Street 1:820 RAVENHILL DR STE 107
Practice Address - Street 2:
Practice Address - City:ATCHISON
Practice Address - State:KS
Practice Address - Zip Code:66002-9252
Practice Address - Country:US
Practice Address - Phone:913-674-2340
Practice Address - Fax:913-674-2039
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS22487207Q00000X
KS0428647208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS103525OtherBLUE CROSS OF KS
KS100458720DMedicaid
KS103525Medicare ID - Type Unspecified
NE277455Medicare PIN
KS100458720DMedicaid
KS080076687Medicare ID - Type UnspecifiedRAILROAD MEDICARE