Provider Demographics
NPI:1003397381
Name:JEANNINE M. RODEMS, MD INC
Entity type:Organization
Organization Name:JEANNINE M. RODEMS, MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANNINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RODEMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-708-1400
Mailing Address - Street 1:9000 SOQUEL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2097
Mailing Address - Country:US
Mailing Address - Phone:831-708-1400
Mailing Address - Fax:831-708-1390
Practice Address - Street 1:9000 SOQUEL AVE STE 100
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2097
Practice Address - Country:US
Practice Address - Phone:831-708-1400
Practice Address - Fax:831-708-1390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1063587376Medicaid
CA1376646463Medicaid