Provider Demographics
NPI:1346651155
Name:ROGERS, EDWINA (MSED)
Entity Type:Individual
Prefix:
First Name:EDWINA
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 GRANITE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-2718
Mailing Address - Country:US
Mailing Address - Phone:718-816-1422
Mailing Address - Fax:718-816-1428
Practice Address - Street 1:1311 55TH STREET
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NEW YORK
Practice Address - Zip Code:11219
Practice Address - Country:UM
Practice Address - Phone:718-851-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY734935131174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist