Provider Demographics
NPI:1538191176
Name:ROODBERGEN, RICHARD (PA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:ROODBERGEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 GENESYS PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8070
Mailing Address - Country:US
Mailing Address - Phone:810-603-0170
Mailing Address - Fax:810-579-1705
Practice Address - Street 1:3452 GENESYS PKWY
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-7334
Practice Address - Country:US
Practice Address - Phone:810-603-0170
Practice Address - Fax:810-579-1705
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003058363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP03156Medicare UPIN