MEDICARE: JACK A. ROGERS JR. M.D.

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
1	208000000X	Pediatrics Physician	GA 017875	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679571988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK A. ROGERS JR. M.D.

Provider Business Mailing Address
First Line	:	114 PLANTATION AVE
Second Line	:
City	:	CEDARTOWN
State	:	GA
Zip	:	30125-2370
Country	:	US
Telephone Number	:	678-901-0717
Fax Number	:	678-901-0718

Provider Business Practice Location Address
First Line	:	114 PLANTATION AVE
Second Line	:
City	:	CEDARTOWN
State	:	GA
Zip	:	30125-2370
Country	:	US
Telephone Number	:	678-901-0717
Fax Number	:	678-901-0718

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2005
Last Update Date	:	12/01/2011

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