Healthcare Provider Details

I. General information

NPI: 1194770016
Provider Name (Legal Business Name): TARA LEIGH ROEDER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 CENTRAL AVE
COLUMBUS IN
47203-1851
US

IV. Provider business mailing address

PO BOX 775383
CHICAGO IL
60677-5383
US

V. Phone/Fax

Practice location:
  • Phone: 812-376-9427
  • Fax:
Mailing address:
  • Phone: 812-376-5315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01059424A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01059424A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: