Provider Demographics
NPI:1497715320
Name:ROEDIGER, TAD M (DC)
Entity Type:Individual
Prefix:
First Name:TAD
Middle Name:M
Last Name:ROEDIGER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 SOUTH ST
Mailing Address - Street 2:BUILDING 2A
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-2805
Mailing Address - Country:US
Mailing Address - Phone:440-285-0756
Mailing Address - Fax:440-285-8625
Practice Address - Street 1:401 SOUTH ST
Practice Address - Street 2:BUILDING 2A
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-2805
Practice Address - Country:US
Practice Address - Phone:440-285-0756
Practice Address - Fax:440-285-8625
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1811111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0868735Medicaid
OH9374121Medicare ID - Type UnspecifiedPROVIDER NUMBER
OH4010993Medicare UPIN