Provider Demographics
NPI:1740489343
Name:ROGERS, TATE M (MD)
Entity type:Individual
Prefix:
First Name:TATE
Middle Name:M
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 1:961 E STUART DR
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2407
Mailing Address - Country:US
Mailing Address - Phone:276-236-9953
Mailing Address - Fax:276-236-6084
Practice Address - Street 1:961 E STUART DR
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2407
Practice Address - Country:US
Practice Address - Phone:276-236-9953
Practice Address - Fax:276-236-6084
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101030999207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2007211081Medicaid
C05711OtherMEDICARE GROUP #
C81132Medicare UPIN
VA2007211081Medicaid