Provider Demographics
NPI:1336636067
Name:ROGERS, ELIJAH
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:ROGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 CLINTON CENTER DR STE 4300
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5610
Mailing Address - Country:US
Mailing Address - Phone:601-815-2005
Mailing Address - Fax:601-815-0434
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4505
Practice Address - Country:US
Practice Address - Phone:601-815-1779
Practice Address - Fax:601-815-0444
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS313362085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology