Basic Information
| Provider Information | |||||||||
| NPI: | 1043316169 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6100 PAN AMERICAN EAST FWY NE | ||||||||
| Address2: | 100 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871093427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057276200 | ||||||||
| FaxNumber: | 5057279590 | ||||||||
| Practice Location | |||||||||
| Address1: | 6100 PAN AMERICAN EAST FWY NE | ||||||||
| Address2: | 100 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871093427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057276200 | ||||||||
| FaxNumber: | 5057279590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 08/12/2015 | ||||||||
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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 | 173000000X | 80242 | NM | N | Other Service Providers | Legal Medicine | 207R00000X | 80242 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00017236 | 05 | NM | MEDICAID |