Provider Demographics
NPI:1790010833
Name:RODGERS, PHILIP GERARD (RN)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:GERARD
Last Name:RODGERS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 GARY ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2870
Mailing Address - Country:US
Mailing Address - Phone:631-828-2792
Mailing Address - Fax:
Practice Address - Street 1:16 GARY ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2870
Practice Address - Country:US
Practice Address - Phone:631-828-2792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-07
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY446862163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult