Provider Demographics
NPI:1265298400
Name:ROGUE MEDICAL LLC
Entity type:Organization
Organization Name:ROGUE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:541-778-4517
Mailing Address - Street 1:205 N PHOENIX RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:OR
Mailing Address - Zip Code:97535-9101
Mailing Address - Country:US
Mailing Address - Phone:541-778-4517
Mailing Address - Fax:541-833-0995
Practice Address - Street 1:205 N PHOENIX RD STE 430
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:OR
Practice Address - Zip Code:97535-9108
Practice Address - Country:US
Practice Address - Phone:541-778-4517
Practice Address - Fax:541-833-0995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty