Provider Demographics
NPI:1609879675
Name:ROGERS, STEPHEN KYLE (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:KYLE
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 1:716 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978-3083
Mailing Address - Country:US
Mailing Address - Phone:219-866-0485
Mailing Address - Fax:219-866-0837
Practice Address - Street 1:716 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-3083
Practice Address - Country:US
Practice Address - Phone:219-866-0485
Practice Address - Fax:219-866-0837
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054781A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
7641531OtherAETNA
020300900OtherFEDCERAL BLACK LUNG
IN200283830Medicaid
000000296595OtherANTHEM BLUE CROSS
P00018889OtherRAILROAD MEDICARE
921430QMedicare ID - Type Unspecified
IN200283830Medicaid