Provider Demographics
NPI:1952350480
Name:ANNIS, ROGER D (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:D
Last Name:ANNIS
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 1:4378 W HOLT RD
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-1666
Mailing Address - Country:US
Mailing Address - Phone:517-694-1466
Mailing Address - Fax:517-694-3530
Practice Address - Street 1:4378 W HOLT RD
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-1666
Practice Address - Country:US
Practice Address - Phone:517-694-1466
Practice Address - Fax:517-694-3530
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRA048224207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RA048224OtherBCBSM
RA048224OtherBCN BLUE CARE NETWORK
MI0100237OtherPHYSICIANS HEALTH PLAN OF
MI102805449Medicaid
MI0170237Medicaid
RA048224OtherBCN BLUE CARE NETWORK
MI0170237Medicaid
C36477001Medicare ID - Type Unspecified