Provider Demographics
NPI:1073504973
Name:COLLINS, ROGER BARRETT (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:BARRETT
Last Name:COLLINS
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 1:105 N GREENLEAF ST
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3326
Mailing Address - Country:US
Mailing Address - Phone:847-623-3090
Mailing Address - Fax:847-623-9620
Practice Address - Street 1:105 N GREENLEAF ST
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3326
Practice Address - Country:US
Practice Address - Phone:847-623-3090
Practice Address - Fax:847-623-9620
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04915144OtherBCBS OF ILLINOIS
L81733Medicare PIN
IL04915144OtherBCBS OF ILLINOIS