1336142025 NPI number — TED B ROGERS MD

Table of content: TED B ROGERS MD (NPI 1336142025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336142025 NPI number — TED B ROGERS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROGERS
Provider First Name:
TED
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1336142025
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
908 WALLACE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEITCHFIELD
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42754-1479
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-259-0124
Provider Business Mailing Address Fax Number:
270-230-0157

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
908 WALLACE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEITCHFIELD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-230-0124
Provider Business Practice Location Address Fax Number:
270-230-0157
Provider Enumeration Date:
05/27/2005

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: 207X00000X , with the licence number:  35858 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000341623 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64086291 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2446228000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50004884 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com