Healthcare Provider Details

I. General information

NPI: 1164999132
Provider Name (Legal Business Name): CHRISTIAN ROEDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 59TH ST W
BRADENTON FL
34209-4604
US

IV. Provider business mailing address

855 N VILLAGE DR N
ST PETERSBURG FL
33716-3056
US

V. Phone/Fax

Practice location:
  • Phone: 941-792-6611
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN9304212
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: