Provider Demographics
NPI:1639116361
Name:ROGERS, JERRY B (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:B
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:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:ONE HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-882-1647
Practice Address - Fax:573-884-6024
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107973208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00106646OtherRR MEDICARE
MOP00419174OtherRAILROAD MEDICARE
MO208049916Medicaid
MO919565236Medicare PIN
MOP00419174OtherRAILROAD MEDICARE
MO208049916Medicaid