Provider Demographics
NPI:1689602815
Name:ROGERS, CRAIG GLENN (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:GLENN
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 1:2799 W GRAND BLVD
Mailing Address - Street 2:K9 UROLOGY
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2608
Mailing Address - Country:US
Mailing Address - Phone:313-916-2641
Mailing Address - Fax:313-916-4900
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:K9 UROLOGY
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-2641
Practice Address - Fax:313-916-4900
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD63779208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD409743200Medicaid
MD409743200Medicaid
MDKS16JHMedicare ID - Type Unspecified
MDI47697Medicare UPIN