Provider Demographics
NPI:1184677734
Name:MORTENSON, RODNEY A (MD)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:A
Last Name:MORTENSON
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 1:520 SOUTH VAN BUREN ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5019
Mailing Address - Country:US
Mailing Address - Phone:336-627-7500
Mailing Address - Fax:
Practice Address - Street 1:518 S VAN BUREN RD
Practice Address - Street 2:CENTRAL BUSINESS OFFICE
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5033
Practice Address - Country:US
Practice Address - Phone:336-623-9711
Practice Address - Fax:336-627-0778
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16532207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8961088Medicaid
209032BMedicare ID - Type Unspecified
NC8961088Medicaid