Healthcare Provider Details

I. General information

NPI: 1841285301
Provider Name (Legal Business Name): ROGER LEON TAYLOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E FAIRMAN AVE
WATSEKA IL
60970-1644
US

IV. Provider business mailing address

375 N WALL ST SUITE P410
KANKAKEE IL
60901-3483
US

V. Phone/Fax

Practice location:
  • Phone: 815-432-7722
  • Fax: 815-432-7822
Mailing address:
  • Phone: 815-932-7474
  • Fax: 815-937-8206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036053609
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: