Healthcare Provider Details

I. General information

NPI: 1881190403
Provider Name (Legal Business Name): JEROME JOHN ROGICH MS, MD, DIMM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

IV. Provider business mailing address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

V. Phone/Fax

Practice location:
  • Phone: 928-779-3366
  • Fax:
Mailing address:
  • Phone: 928-214-3930
  • Fax: 928-214-3882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA174255
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberA780935
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: