Basic Information
| Provider Information | |||||||||
| NPI: | 1700959509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODGERS | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 530 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FORT LEE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070244506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015926200 | ||||||||
| FaxNumber: | 2015926401 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FORT LEE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070244506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015926200 | ||||||||
| FaxNumber: | 2015926401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | NJ | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 5000009 | 05 | NJ | MEDICAID |