Provider Demographics
NPI:1871001115
Name:RODGERS, MATTHEW (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:RODGERS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 CORLISS AVE APT 107
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2071
Mailing Address - Country:US
Mailing Address - Phone:607-763-6735
Mailing Address - Fax:607-763-6736
Practice Address - Street 1:57 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-1476
Practice Address - Country:US
Practice Address - Phone:607-763-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY643983207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology