1003112376 NPI number — ROGERS W WOOD JR. RPH

Table of content: ROGERS W WOOD JR. RPH (NPI 1003112376)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003112376 NPI number — ROGERS W WOOD JR. RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOOD
Provider First Name:
ROGERS
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
RPH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOOD
Provider Other First Name:
CHIP
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RPH
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1003112376
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
54 E JARMAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAZLEHURST
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-375-9893
Provider Business Mailing Address Fax Number:
912-375-3214

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
54 E JARMAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZLEHURST
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-375-9893
Provider Business Practice Location Address Fax Number:
912-375-3214
Provider Enumeration Date:
02/04/2011

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: 183500000X , with the licence number:  RPH013011 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 461799980 . This is a "UPDATED TAX ID" identifier . This identifiers is of the category "OTHER".