Provider Demographics
NPI:1881682789
Name:ROEDIGER, JOHN H (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:ROEDIGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:1250 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1897
Practice Address - Country:US
Practice Address - Phone:207-797-5753
Practice Address - Fax:207-797-9571
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD8727207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEB86271OtherHARVARD PILGRIM
ME302230099Medicaid
ME1044199OtherAETNA
ME040512OtherANTHEM
MEB86271Medicare UPIN
ME11630102Medicare PIN
ME116301Medicare PIN
MEB86271OtherHARVARD PILGRIM
ME040512OtherANTHEM
ME11630103Medicare PIN