Provider Demographics
NPI:1437170586
Name:RODERER, GRANT T (MD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:T
Last Name:RODERER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 ABBOTT RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-3448
Mailing Address - Country:US
Mailing Address - Phone:907-278-2741
Mailing Address - Fax:907-743-8284
Practice Address - Street 1:1917 ABBOTT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507
Practice Address - Country:US
Practice Address - Phone:907-278-2741
Practice Address - Fax:907-743-8284
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AKAK4470207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD0183Medicaid
AK151584Medicare ID - Type Unspecified
AKMD0183Medicaid