Healthcare Provider Details

I. General information

NPI: 1609627231
Provider Name (Legal Business Name): WILLARD BLAINE ROGERS MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 CAMBRIDGE PLZ
CAMBRIDGE MD
21613-2531
US

IV. Provider business mailing address

720 CAMBRIDGE PLZ
CAMBRIDGE MD
21613-2531
US

V. Phone/Fax

Practice location:
  • Phone: 443-769-3969
  • Fax: 571-699-2950
Mailing address:
  • Phone: 443-769-3969
  • Fax: 571-699-2950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: