Provider Demographics
NPI:1922454388
Name:ROODHOUSE, KEVIN ANDREW
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANDREW
Last Name:ROODHOUSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1338 MOUND AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-2252
Mailing Address - Country:US
Mailing Address - Phone:217-622-9939
Mailing Address - Fax:
Practice Address - Street 1:7703 FLOYD CURL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3901
Practice Address - Country:US
Practice Address - Phone:210-567-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361632382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology