Provider Demographics
NPI:1336142025
Name:ROGERS, TED B (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:B
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 1:908 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-1479
Mailing Address - Country:US
Mailing Address - Phone:270-259-0124
Mailing Address - Fax:270-230-0157
Practice Address - Street 1:908 WALLACE AVE
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754
Practice Address - Country:US
Practice Address - Phone:270-230-0124
Practice Address - Fax:270-230-0157
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35858207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000341623OtherANTHEM
KY64086291Medicaid
KY2446228000OtherPASSPORT ADVANTAGE
KY50004884OtherPASSPORT
KY2446228000OtherPASSPORT ADVANTAGE
I13361Medicare UPIN