Provider Demographics
NPI:1932334166
Name:RODERICK, MARILYN ANNE (M,D,)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:ANNE
Last Name:RODERICK
Suffix:
Gender:F
Credentials:M,D,
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:60 COMMERCE PLAZA CIR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-7386
Mailing Address - Country:US
Mailing Address - Phone:910-521-2900
Mailing Address - Fax:910-775-9165
Practice Address - Street 1:15 HILL PLZ
Practice Address - Street 2:SUITE A
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-4950
Practice Address - Country:US
Practice Address - Phone:910-207-6440
Practice Address - Fax:910-207-6444
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG-53149208D00000X
NC200401311208D00000X, 208D00000X
HIMD-11467208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA52454Medicare UPIN