Provider Demographics
NPI:1235179508
Name:ROGERS, KATHLEEN S (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:S
Last Name:ROGERS
Suffix:
Gender:F
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 7609
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59807-7609
Mailing Address - Country:US
Mailing Address - Phone:406-721-5600
Mailing Address - Fax:406-721-3907
Practice Address - Street 1:2835 FORT MISSOULA ROAD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7408
Practice Address - Country:US
Practice Address - Phone:406-721-5600
Practice Address - Fax:406-721-3907
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT5347208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0057369Medicaid
D20589Medicare UPIN
MT000009318Medicare ID - Type Unspecified