Healthcare Provider Details

I. General information

NPI: 1841393311
Provider Name (Legal Business Name): MARK RODEFELD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 12/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 RILEY HOSPITAL DR
INDIANAPOLIS IN
46202-5109
US

IV. Provider business mailing address

PO BOX 636762
CINCINNATI OH
45263-6762
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-7150
  • Fax: 317-274-2940
Mailing address:
  • Phone: 317-948-0944
  • Fax: 317-274-2940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number01054552
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number01054552A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: