Provider Demographics
NPI:1699721852
Name:DIPPEL, RODERICK TAYLOR (MD,)
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:TAYLOR
Last Name:DIPPEL
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:P.O. BOX 403631
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30284-3631
Mailing Address - Country:US
Mailing Address - Phone:770-740-0895
Mailing Address - Fax:770-740-0896
Practice Address - Street 1:955 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5441
Practice Address - Country:US
Practice Address - Phone:843-522-5005
Practice Address - Fax:843-522-5017
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17989207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT19584Medicaid
SC7524Medicare ID - Type Unspecified
SCT19584Medicaid
SCSC16365019Medicare PIN
SCSC16369068Medicare PIN
SCP01250199Medicare PIN