Basic Information
| Provider Information | |||||||||
| NPI: | 1134115504 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | BERNARD | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 GRAMPIAN BLVD | ||||||||
| Address2: | STE 3A | ||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177011900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703224025 | ||||||||
| FaxNumber: | 5703226403 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | LEWISTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170441167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172427298 | ||||||||
| FaxNumber: | 7172427741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 11/12/2022 | ||||||||
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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 | 2085R0001X | MD040233E | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 001241063 | 05 | PA | MEDICAID |