Basic Information
| Provider Information | |||||||||
| NPI: | 1487619417 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | TRENT | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WEST TIETAN STREET | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993624445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095253720 | ||||||||
| FaxNumber: | 5095221593 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 WEST TIETAN STREET | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993624445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095253720 | ||||||||
| FaxNumber: | 5095221593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 07/15/2010 | ||||||||
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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 | 208000000X | 2000150925 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD60150941 | WA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 129168 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 204956502 | 05 | MO | MEDICAID | 3269222 | 01 | CIGNA | OTHER | H13706 | 01 | MERCY | OTHER | 1834225 | 01 | FIRST HEALTH | OTHER | 4435458 | 01 | HEALTHLINK | OTHER | 204956502 | 01 | MO | MEDICAID | OTHER | 207515500 | 01 | MO | MEDICAID | OTHER | 440546366 | 01 | UNITED HEALTHCARE | OTHER |