Provider Demographics
NPI:1558388421
Name:ROERDEN, KEVIN H (CRNA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:H
Last Name:ROERDEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 869
Mailing Address - Street 2:
Mailing Address - City:FOLLY BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29439-0869
Mailing Address - Country:US
Mailing Address - Phone:843-588-6378
Mailing Address - Fax:843-588-6378
Practice Address - Street 1:501 ROBERTSON BLVD
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-2787
Practice Address - Country:US
Practice Address - Phone:843-549-0720
Practice Address - Fax:843-549-6254
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1996367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1284Medicaid
SCAN1284Medicaid
SCQ08232Medicare UPIN