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General NPI Number Information
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NPI Number | 1235417056
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Entity Type | Individual
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Provider Name | MR. RODERICK BERTRAM EWING SR.
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Gender | Male
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Dates
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Enumeration Date | 07/27/2011
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Last Update Date | 07/27/2011
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Provider Practice Location Address
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Address Line | 3412 DEODAR ST
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City | EAST CHICAGO
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State | IN
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Zip | 46312-2024
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Country | US
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Telephone | 219-381-7235
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Fax |
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Provider Business Mailing Address
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Address Line | 3412 DEODAR ST
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City | EAST CHICAGO
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State | IN
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Zip | 46312-2024
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Country | US
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Telephone | 219-381-7235
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 344600000X
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Taxonomy Name | Taxi
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License Number | 0410-21-5033
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License Number State | IN
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