Basic Information
Provider Information | |||||||||
NPI: | 1457558504 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROGERS | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | KENNETH | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARRT,R | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13408 HERITAGE DR | ||||||||
Address2: |   | ||||||||
City: | KEARNEY | ||||||||
State: | MO | ||||||||
PostalCode: | 640608007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9136822000 | ||||||||
FaxNumber: | 9137584174 | ||||||||
Practice Location | |||||||||
Address1: | 13408 HERITAGE DR | ||||||||
Address2: |   | ||||||||
City: | KEARNEY | ||||||||
State: | MO | ||||||||
PostalCode: | 640608007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9136822000 | ||||||||
FaxNumber: | 9137584174 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471C3402X | 420476 | MO | Y |   | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Radiography |
No ID Information.