Healthcare Provider Details

I. General information

NPI: 1710100698
Provider Name (Legal Business Name): MARY JANE ROGALSKI RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

759 CHESTNUT ST BAYSTATE MEDICAL CENTER C1340
SPRINGFIELD MA
01199-1001
US

IV. Provider business mailing address

32 WELLS PARK RD
STURBRIDGE MA
01566-1316
US

V. Phone/Fax

Practice location:
  • Phone: 413-794-4954
  • Fax: 413-794-4949
Mailing address:
  • Phone: 508-347-7650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number507
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: