Provider Demographics
NPI:1881648418
Name:KELLOGG, ROGER (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:KELLOGG
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 1:286 HOSPITAL LOOP
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BERLIN
Mailing Address - State:VT
Mailing Address - Zip Code:05602-9523
Mailing Address - Country:US
Mailing Address - Phone:802-229-0010
Mailing Address - Fax:802-229-4867
Practice Address - Street 1:286 HOSPITAL LOOP
Practice Address - Street 2:SUITE 5
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9523
Practice Address - Country:US
Practice Address - Phone:802-229-0010
Practice Address - Fax:802-229-4867
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.0004847207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVT4792Medicare PIN