Provider Demographics
NPI:1457381980
Name:ROGERS, JERRY P (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:P
Last Name:ROGERS
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 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:801 BELSLY BLVD
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5055
Practice Address - Country:US
Practice Address - Phone:701-364-6800
Practice Address - Fax:701-364-6828
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25477207Q00000X
ND4728207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN14614Medicaid
ND28527ROOtherMNBS #
MN6439OtherNDBS #
MN664582OtherAMERICA'S PPO/ARAZ #
MN0106001OtherMEDICA #
ND1739OtherNDBS #
MNDA9011015630OtherPREFERRED ONE #
MN080039937OtherRAILROAD
ND1739OtherND MEDICARE #
MNMN100035OtherLHS #
MN122946OtherUCARE #
ND0108164OtherMEDICA #
MNHP19577OtherHEALTHPARTNERS #
MN15959OtherSIOUX VALLEY #
ND0106002OtherMEDICA #
NC27362ROOtherMNBS #
MN83D94ROOtherMNBS #
MN944307000Medicaid
MNHP19577OtherHEALTHPARTNERS #
ND1739OtherNDBS #