Healthcare Provider Details

I. General information

NPI: 1326014564
Provider Name (Legal Business Name): ROGER L GEBHARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST MC 11503F
SAINT PAUL MN
55101-2502
US

IV. Provider business mailing address

8100 34TH AVE S 21110Q
BLOOMINGTON MN
55425-1672
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-2327
  • Fax: 651-254-1553
Mailing address:
  • Phone: 952-883-7961
  • Fax: 952-883-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number19152
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: