Provider Demographics
NPI:1013455195
Name:DAVIS, RODERICK
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RODERICK
Other - Middle Name:M
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:806 IRWIN AVE
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:MI
Mailing Address - Zip Code:49224-2054
Mailing Address - Country:US
Mailing Address - Phone:517-937-6721
Mailing Address - Fax:517-748-7034
Practice Address - Street 1:806 IRWIN AVE
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:MI
Practice Address - Zip Code:49224-2054
Practice Address - Country:US
Practice Address - Phone:517-937-6721
Practice Address - Fax:517-748-7034
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF3803818633747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI$$$$$$$$$OtherSPECIALIZED PAY(CMH)
MI$$$$$$$$$Medicaid