Basic Information
| Provider Information | |||||||||
| NPI: | 1164832481 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | TYRONE | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176211647 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8040 CLEARVISTA PKWY STE 490 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462565604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176215450 | ||||||||
| FaxNumber: | 3176215453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2014 | ||||||||
| LastUpdateDate: | 10/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | 01083772A | IN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 300038778 | 05 | IN | MEDICAID |