Healthcare Provider Details

I. General information

NPI: 1528064581
Provider Name (Legal Business Name): ROGER ALAN HISER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 05/08/2020
Certification Date: 05/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 GENTILLY BLVD
CARTERSVILLE GA
30120-8522
US

IV. Provider business mailing address

221 TECHNOLOGY PKWY NW
ROME GA
30165-1369
US

V. Phone/Fax

Practice location:
  • Phone: 470-490-6030
  • Fax: 470-490-6029
Mailing address:
  • Phone: 762-235-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number48899
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number48899
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: