Provider Demographics
NPI:1649411158
Name:RODGMAN, MARION SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:SUSAN
Last Name:RODGMAN
Suffix:
Gender:F
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 969
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-0969
Mailing Address - Country:US
Mailing Address - Phone:620-786-6475
Mailing Address - Fax:620-786-6155
Practice Address - Street 1:3520 LAKIN AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3660
Practice Address - Country:US
Practice Address - Phone:620-792-3345
Practice Address - Fax:620-792-3767
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-25143208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100161240CMedicaid
KS1649411158OtherBCBSKS
KS100161240CMedicaid