Basic Information
Provider Information | |||||||||
NPI: | 1568406999 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROGER ROGALSKI MD CHTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2874 N CARSON ST | ||||||||
Address2: | #105 | ||||||||
City: | CARSON CITY | ||||||||
State: | NV | ||||||||
PostalCode: | 897060177 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7758419991 | ||||||||
FaxNumber: | 7758419485 | ||||||||
Practice Location | |||||||||
Address1: | 619 NEW YORK RANCH RD | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | CA | ||||||||
PostalCode: | 956429328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8005443955 | ||||||||
FaxNumber: | 5305442359 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/15/2006 | ||||||||
LastUpdateDate: | 01/04/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROGALSKI | ||||||||
AuthorizedOfficialFirstName: | ROGER | ||||||||
AuthorizedOfficialMiddleName: | PAUL | ||||||||
AuthorizedOfficialTitleorPosition: | PRES SEC ETC | ||||||||
AuthorizedOfficialTelephone: | 7758419991 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 6391 | NV | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XX0005X | 6391 | NV | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0005X | G71822 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | G71822 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 00G718220 | 01 | CA | CALIF MEDI-CAL | OTHER |