Provider Demographics
NPI:1609857259
Name:ROGERS, RUSSELL KEVIN (MD)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:KEVIN
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 1:1461 N GARDNER ST
Mailing Address - Street 2:PO BOX 407
Mailing Address - City:SCOTTSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47170-7751
Mailing Address - Country:US
Mailing Address - Phone:812-752-4656
Mailing Address - Fax:812-752-4919
Practice Address - Street 1:1461 N GARDNER ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-7751
Practice Address - Country:US
Practice Address - Phone:812-752-4656
Practice Address - Fax:812-752-4919
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035467207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100221450AMedicaid
KY000000042514OtherANTHEM
IN100221450AMedicaid
IN730670Medicare ID - Type Unspecified