1790774354 NPI number — CAROL M ROGERS CONP

Table of content: CAROL M ROGERS CONP (NPI 1790774354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790774354 NPI number — CAROL M ROGERS CONP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROGERS
Provider First Name:
CAROL
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CONP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790774354
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 HARRISON ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13790-2161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-763-6850
Provider Business Mailing Address Fax Number:
607-763-6703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 HARRISON ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13790-2161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-763-6850
Provider Business Practice Location Address Fax Number:
607-763-6703
Provider Enumeration Date:
10/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  F3700121 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 363LF0000X , with the licence number: F3301131 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02204277 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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