Provider Demographics
NPI:1003966656
Name:ROGER L LAND MD PC
Entity type:Organization
Organization Name:ROGER L LAND MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-870-4435
Mailing Address - Street 1:2051B HAMILL RD
Mailing Address - Street 2:SUITE101
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4085
Mailing Address - Country:US
Mailing Address - Phone:423-870-4435
Mailing Address - Fax:423-870-4685
Practice Address - Street 1:2051B HAMILL RD
Practice Address - Street 2:SUITE101
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4085
Practice Address - Country:US
Practice Address - Phone:423-870-4435
Practice Address - Fax:423-870-4685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD21156208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3058053Medicaid
TN4012527OtherBLUE CROSS OT TN
TN4012527OtherBLUE CROSS OT TN
TN3058053Medicaid