Healthcare Provider Details

I. General information

NPI: 1891027173
Provider Name (Legal Business Name): MRS. RUTH ALMA ROEDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2010
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN 3RD FLOOR MAIN BLDG CHILDREN'S HOSPITAL OF MI
DETROIT MI
48201
US

IV. Provider business mailing address

4201 ST. ANTOINE UHC 6F MAILBOX# 226 UNIVERSITY PEDIATRICIANS
DETROIT MI
48201
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5906
  • Fax: 313-745-0955
Mailing address:
  • Phone: 313-966-5051
  • Fax: 313-966-6618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704128683
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704128683
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: