Healthcare Provider Details

I. General information

NPI: 1235258260
Provider Name (Legal Business Name): CHARLES LEWIS ROGERS OPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 TRINITY LN SUITE 111
BLOOMINGTON IL
61704-8111
US

IV. Provider business mailing address

1111 TRINITY LN SUITE 111
BLOOMINGTON IL
61704-8111
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-6461
  • Fax: 309-663-5711
Mailing address:
  • Phone: 309-663-6461
  • Fax: 309-663-5711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number238.000269
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: