Provider Demographics
NPI:1235417056
Name:EWING, RODERICK BERTRAM SR
Entity Type:Individual
Prefix:MR
First Name:RODERICK
Middle Name:BERTRAM
Last Name:EWING
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3412 DEODAR ST
Mailing Address - Street 2:
Mailing Address - City:EAST CHICAGO
Mailing Address - State:IN
Mailing Address - Zip Code:46312-2024
Mailing Address - Country:US
Mailing Address - Phone:219-381-7235
Mailing Address - Fax:
Practice Address - Street 1:3412 DEODAR ST
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-2024
Practice Address - Country:US
Practice Address - Phone:219-381-7235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-27
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0410-21-5033344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi