Provider Demographics
NPI:1235223926
Name:RODDY, ELIZABETH GAILE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:GAILE
Last Name:RODDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10051 5TH ST N STE 200
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2211
Mailing Address - Country:US
Mailing Address - Phone:727-733-5100
Mailing Address - Fax:727-447-4827
Practice Address - Street 1:1551 MAIN ST
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-4650
Practice Address - Country:US
Practice Address - Phone:727-733-5100
Practice Address - Fax:727-447-4827
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084488207Q00000X
SC52315207Q00000X
NC2018-01179207Q00000X
FLME102085207Q00000X
KY51481207Q00000X
TN57419207Q00000X
DCMD046113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013671400Medicaid
FL013671400Medicaid
FLHZ799ZMedicare PIN
MI0M33350111Medicare ID - Type Unspecified
MI4917444Medicaid
MII61881Medicare UPIN
MI4917435Medicaid
ID381360529OtherTAX ID
MI4917453Medicaid
MI4917426Medicaid