Provider Demographics
NPI:1619998721
Name:JIM W. RODERIQUE, M.D., P.C.
Entity Type:Organization
Organization Name:JIM W. RODERIQUE, M.D., P.C.
Other - Org Name:THE RODERIQUE CENTRE FOR HAND AND UPPER EXTREMITY SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:T
Authorized Official - Last Name:CAUDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-872-4263
Mailing Address - Street 1:955 SPRING ST NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3821
Mailing Address - Country:US
Mailing Address - Phone:404-872-4263
Mailing Address - Fax:404-873-2455
Practice Address - Street 1:955 SPRING ST NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-3821
Practice Address - Country:US
Practice Address - Phone:404-872-4263
Practice Address - Fax:404-873-2455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA55002692AMedicaid
GA2660Medicare ID - Type Unspecified