Healthcare Provider Details

I. General information

NPI: 1619288438
Provider Name (Legal Business Name): MARY BLAIR-ROGERS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY BLAIR-GISCOMBE

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 BRUCEVILLE RD
SACRAMENTO CA
95823-4671
US

IV. Provider business mailing address

6600 BRUCEVILLE RD
SACRAMENTO CA
95823-4671
US

V. Phone/Fax

Practice location:
  • Phone: 916-688-2000
  • Fax:
Mailing address:
  • Phone: 916-688-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR72272
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22766
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberA138664
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: