Healthcare Provider Details

I. General information

NPI: 1215459854
Provider Name (Legal Business Name): RODERICK DARNELL SHINE CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2017
Last Update Date: 07/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 E SOUTH BLVD
MONTGOMERY AL
36116-2409
US

IV. Provider business mailing address

90 EMERALD DR
PIKE ROAD AL
36064-2932
US

V. Phone/Fax

Practice location:
  • Phone: 334-288-2100
  • Fax:
Mailing address:
  • Phone: 334-294-8029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number1-120663
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: