Healthcare Provider Details

I. General information

NPI: 1033435623
Provider Name (Legal Business Name): TRENT ROEDERER PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 09/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 E MAIN ST SUITE 148
MCCONNELSVILLE OH
43756-1296
US

IV. Provider business mailing address

133 ROSEMAR RD STE 1
PARKERSBURG WV
26104-7609
US

V. Phone/Fax

Practice location:
  • Phone: 740-962-4441
  • Fax: 740-962-4488
Mailing address:
  • Phone: 304-295-3060
  • Fax: 304-295-3068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number012758
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: