Provider Demographics
NPI:1811045420
Name:KERN, ROGER M
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:M
Last Name:KERN
Suffix:
Gender:M
Credentials:
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 3160
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85217-3160
Mailing Address - Country:US
Mailing Address - Phone:480-288-5328
Mailing Address - Fax:480-288-5339
Practice Address - Street 1:564 N IDAHO RD
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85219-4001
Practice Address - Country:US
Practice Address - Phone:480-288-5328
Practice Address - Fax:480-288-5339
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC 10208101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ164397Medicaid