1114979614 NPI number — SEACOAST ORTHOPEDIC SURGERY & SPORTS MEDICINE LLC

Table of content: CHARLES GILBERT ROGERS JR. M.D. (NPI 1902938657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114979614 NPI number — SEACOAST ORTHOPEDIC SURGERY & SPORTS MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEACOAST ORTHOPEDIC SURGERY & SPORTS MEDICINE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1114979614
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
495 ROUTE 184
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
GROTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-449-1413
Provider Business Mailing Address Fax Number:
860-449-0390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
495 ROUTE 184
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
GROTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-449-1413
Provider Business Practice Location Address Fax Number:
860-449-0390
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARLOW
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
860-449-1413

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 047870 . This is a "LICENSE NUMBER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 001409756 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001272939 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 040975 . This is a "LICENSE NUMBER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 001253582 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004237146 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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