Healthcare Provider Details

I. General information

NPI: 1558560052
Provider Name (Legal Business Name): JEFFREY RODEBAUGH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 AVENUE B
RICHWOOD WV
26261-1207
US

IV. Provider business mailing address

74 AVENUE B
RICHWOOD WV
26261
US

V. Phone/Fax

Practice location:
  • Phone: 304-846-4980
  • Fax: 304-846-4984
Mailing address:
  • Phone: 304-846-4980
  • Fax: 304-846-4984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24042
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: