Provider Demographics
NPI:1255437117
Name:RODBERG, GARY MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:MICHAEL
Last Name:RODBERG
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 1:800 N JUSTICE ST # 16
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28791-3410
Mailing Address - Country:US
Mailing Address - Phone:828-694-8385
Mailing Address - Fax:828-694-7654
Practice Address - Street 1:705 6TH AVE W STE A
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28739
Practice Address - Country:US
Practice Address - Phone:828-696-2570
Practice Address - Fax:828-693-0608
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201501339207RP1001X, 207RP1001X
MS14252207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCP859AOtherMEDICARE PTAN
MS00114969Medicaid
640862267OtherEIN
F97896Medicare UPIN
MS00114969Medicaid