Provider Demographics
NPI:1003893371
Name:ROGERS, BARRY L (MD)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:L
Last Name:ROGERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MEMORIAL DR
Mailing Address - Street 2:STE 2000
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-1243
Mailing Address - Country:US
Mailing Address - Phone:920-361-5340
Mailing Address - Fax:920-361-5335
Practice Address - Street 1:225 MEMORIAL DR
Practice Address - Street 2:STE 2000
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1243
Practice Address - Country:US
Practice Address - Phone:920-361-5340
Practice Address - Fax:920-361-5335
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI24248208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30416700Medicaid
WIB5616Medicare UPIN
WI30416700Medicaid