Provider Demographics
NPI:1487677167
Name:ROGERS, PHILLIP RAYMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:RAYMOND
Last Name:ROGERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1776 OLD SPRING HOUSE LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6225
Mailing Address - Country:US
Mailing Address - Phone:770-454-0091
Mailing Address - Fax:770-454-0095
Practice Address - Street 1:1776 OLD SPRING HOUSE LN
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6225
Practice Address - Country:US
Practice Address - Phone:770-454-0091
Practice Address - Fax:770-454-0095
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21197207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003129768AMedicaid
GA003129768CMedicaid
GA003129768BMedicaid
GA003129768BMedicaid
GA003129768CMedicaid