Provider Demographics
NPI:1639351638
Name:KENNETH F RODGERS MD PA
Entity Type:Organization
Organization Name:KENNETH F RODGERS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:F
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-236-2202
Mailing Address - Street 1:1707 LINWOOD DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450
Mailing Address - Country:US
Mailing Address - Phone:870-236-2202
Mailing Address - Fax:870-236-8428
Practice Address - Street 1:1707 LINWOOD DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450
Practice Address - Country:US
Practice Address - Phone:870-236-2202
Practice Address - Fax:870-236-8428
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNETH F RODGERS MD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-30
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7528207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209217702OtherGTE DATA SERVICES MEDICAI
AR118700001Medicaid
E50487Medicare UPIN
54178Medicare PIN