Basic Information
| Provider Information | |||||||||
| NPI: | 1457381980 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 BELSLY BLVD | ||||||||
| Address2: | |||||||||
| City: | MOORHEAD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565605055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013646800 | ||||||||
| FaxNumber: | 7013646828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 10/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25477 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4728 | ND | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 14614 | 05 | MN | MEDICAID | 28527RO | 01 | ND | MNBS # | OTHER | 6439 | 01 | MN | NDBS # | OTHER | 664582 | 01 | MN | AMERICA'S PPO/ARAZ # | OTHER | 0106001 | 01 | MN | MEDICA # | OTHER | 1739 | 01 | ND | NDBS # | OTHER | DA9011015630 | 01 | MN | PREFERRED ONE # | OTHER | 080039937 | 01 | MN | RAILROAD | OTHER | 1739 | 01 | ND | ND MEDICARE # | OTHER | MN100035 | 01 | MN | LHS # | OTHER | 122946 | 01 | MN | UCARE # | OTHER | 0108164 | 01 | ND | MEDICA # | OTHER | HP19577 | 01 | MN | HEALTHPARTNERS # | OTHER | 15959 | 01 | MN | SIOUX VALLEY # | OTHER | 0106002 | 01 | ND | MEDICA # | OTHER | 27362RO | 01 | NC | MNBS # | OTHER | 83D94RO | 01 | MN | MNBS # | OTHER | 944307000 | 05 | MN | MEDICAID |