=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558857920
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEGAN DAVIS ROGERS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2018
-----------------------------------------------------
Last Update Date | 05/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 E WARWICK DR STE 3
-----------------------------------------------------
City | ALMA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48801-1083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-463-6699
-----------------------------------------------------
Fax | 989-466-2574
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11441 S FRANCIS RD
-----------------------------------------------------
City | DEWITT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48820-9141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | C0006867
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------