Provider Demographics
NPI:1093787061
Name:KERLEY, ROGER K (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:K
Last Name:KERLEY
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:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-719-6100
Mailing Address - Fax:336-719-2313
Practice Address - Street 1:865 W LAKE DR
Practice Address - Street 2:
Practice Address - City:MT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2157
Practice Address - Country:US
Practice Address - Phone:336-719-6100
Practice Address - Fax:336-719-2313
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24602207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8948548Medicaid
C81400Medicare UPIN
NC202663CMedicare ID - Type Unspecified