Provider Demographics
NPI:1942218862
Name:RODERICK ROSEBERRY, ROSEMARY H (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSEMARY
Middle Name:H
Last Name:RODERICK ROSEBERRY
Suffix:
Gender:F
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:BROOKE ARMY MEDICAL CENTER
Mailing Address - Street 2:3551 ROGER BROOKE DR.
Mailing Address - City:JBSA FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-3160
Mailing Address - Fax:
Practice Address - Street 1:BROOKE ARMY MEDICAL CENTER
Practice Address - Street 2:3551 ROGER BROOKE DR.
Practice Address - City:JBSA FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:214-395-7573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0228208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116436002Medicaid
TX370007273OtherRR MEDICARE
TX116436002Medicaid
TX87W709Medicare ID - Type Unspecified