Provider Demographics
NPI:1932134889
Name:BROOKSBANK, ROGER A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:A
Last Name:BROOKSBANK
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:PO BOX 634706
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1924 ALCOA HWY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1511
Practice Address - Country:US
Practice Address - Phone:865-544-9000
Practice Address - Fax:865-539-8008
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN019705207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3073712Medicaid
TN3049873OtherBLUE CROSS
GA00496306AMedicaid
TN3081215OtherBLUE CROSS
TN3835651Medicaid
TN0128420OtherBLUE CROSS
TN3817576Medicaid
TNP00231945OtherRAILROAD MEDICARE
KY64030901Medicaid
TN3835651Medicare PIN
TN3081215OtherBLUE CROSS
TNE92309Medicare UPIN
TN3073712Medicaid