Provider Demographics
NPI:1023034170
Name:ROEDER, BRIAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:ROEDER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 HOSPITAL DR
Mailing Address - Street 2:SUITE 803
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5803
Mailing Address - Country:US
Mailing Address - Phone:410-553-8160
Mailing Address - Fax:410-553-8159
Practice Address - Street 1:301 HOSPITAL DR
Practice Address - Street 2:SUITE 803
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5803
Practice Address - Country:US
Practice Address - Phone:410-553-8160
Practice Address - Fax:410-553-8159
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC00624363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD236285OtherKAISER PERM
MD75551OtherAMERIGROUP
S62039Medicare UPIN
MD75551OtherAMERIGROUP