Provider Demographics
NPI:1629579081
Name:ROGERS, PHILLIP DALE
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:DALE
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 1:536 NORVILLE DR NW
Mailing Address - Street 2:
Mailing Address - City:RESACA
Mailing Address - State:GA
Mailing Address - Zip Code:30735-6174
Mailing Address - Country:US
Mailing Address - Phone:706-280-3991
Mailing Address - Fax:
Practice Address - Street 1:536 NORVILLE DR NW
Practice Address - Street 2:
Practice Address - City:RESACA
Practice Address - State:GA
Practice Address - Zip Code:30735-6174
Practice Address - Country:US
Practice Address - Phone:706-280-3991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker