Healthcare Provider Details

I. General information

NPI: 1609879675
Provider Name (Legal Business Name): STEPHEN KYLE ROGERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 S COLLEGE AVE
RENSSELAER IN
47978-3083
US

IV. Provider business mailing address

716 S COLLEGE AVE
RENSSELAER IN
47978-3083
US

V. Phone/Fax

Practice location:
  • Phone: 219-866-0485
  • Fax: 219-866-0837
Mailing address:
  • Phone: 219-866-0485
  • Fax: 219-866-0837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01054781A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: