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NPI Code Detail

MEDICARE: DR. JOHN RYAN RODENBOUGH PSYD

MEDICARE: DR. JOHN RYAN RODENBOUGH PSYD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103TC0700XClinical Psychologist2257NC
2103T00000XPsychologist2257NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
10405VOTHERNCBCBS NC
25857267OTHERNCAETNA
3B5701OTHERNCMEDCOST

General Provider Information

NPI Number : 1932140779
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JOHN RYAN RODENBOUGH PSYD
Provider Business Mailing Address
First Line : 1200 N ELM ST
Second Line :
City : GREENSBORO
State : NC
Zip : 27401-1004
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1126 N CHURCH ST STE 103
Second Line :
City : GREENSBORO
State : NC
Zip : 27401-1035
Country : US
Telephone Number : 336-663-4900
Fax Number : 336-663-4920
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/10/2006
Last Update Date : 08/13/2021

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