Basic Information
| Provider Information | |||||||||
| NPI: | 1285641530 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | JARED | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618203909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173661326 | ||||||||
| FaxNumber: | 2173666106 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 WINDSOR RD | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618226217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173668130 | ||||||||
| FaxNumber: | 2173666106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 08/15/2012 | ||||||||
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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 | 036084031 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 36084031 | 01 | IL | BCBS | OTHER | 080190838 | 01 | IL | RAILROAD MEDICARE | OTHER | 023284 | 01 | IL | HEALTH ALLIANCE | OTHER | 472301 | 01 | IL | HEALTHLINK | OTHER | 7215059 | 01 | IL | BCBS PPO | OTHER | IL01N1 | 01 | IL | JOHN DEERE | OTHER | 036084031 | 05 | IL | MEDICAID | 0360840311 | 05 | IL | MEDICAID |