Basic Information
| Provider Information | |||||||||
| NPI: | 1285723635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1105 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462061105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185495361 | ||||||||
| FaxNumber: | 6183514821 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 W JACKSON STE 102 | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184570456 | ||||||||
| FaxNumber: | 6184572222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 09/11/2014 | ||||||||
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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 | 036065012 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 002824 | 01 | HEALTH ALLIANCE | OTHER | 036065012 | 05 | IL | MEDICAID | 104271 | 01 | IL | HEALTH LINK | OTHER | 03925819 | 01 | IL | BCBS | OTHER |