=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457381980
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY P ROGERS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2006
-----------------------------------------------------
Last Update Date | 10/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 BELSLY BLVD
-----------------------------------------------------
City | MOORHEAD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56560-5055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-364-6800
-----------------------------------------------------
Fax | 701-364-6828
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6001
-----------------------------------------------------
City | FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58108-6001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-364-3300
-----------------------------------------------------
Fax | 701-364-8906
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25477
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 4728
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------