Provider Demographics
NPI:1801869151
Name:ROGERS FAMILY AND OCCUPATIONAL MEDICINE CLINIC
Entity type:Organization
Organization Name:ROGERS FAMILY AND OCCUPATIONAL MEDICINE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:YAWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-621-9749
Mailing Address - Street 1:1615B WEST PERSIMMON
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756
Mailing Address - Country:US
Mailing Address - Phone:479-636-7192
Mailing Address - Fax:479-621-9749
Practice Address - Street 1:1615B WEST PERSIMMON
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756
Practice Address - Country:US
Practice Address - Phone:479-636-7192
Practice Address - Fax:479-621-9749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5B378OtherBLUE CROSS BLUE SHIELD
AR5B378Medicare ID - Type Unspecified