Basic Information
| Provider Information | |||||||||
| NPI: | 1215000393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 GREEN COVE DR | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773568267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365976065 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 605 HOLDERRIETH BLVD | ||||||||
| Address2: | |||||||||
| City: | TOMBALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773756445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814017500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 01/19/2011 | ||||||||
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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 | 207P00000X | F5873 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8AP261 | 01 | TX | BCBS | OTHER | 139287017 | 05 | TX | MEDICAID |