Basic Information
| Provider Information | |||||||||
| NPI: | 1942299227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAAGE | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 N 8TH AVE E | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187231112 | ||||||||
| FaxNumber: | 2187230015 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 N 8TH AVE E | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187231112 | ||||||||
| FaxNumber: | 2187230015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 23375 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30226800 | 05 | WI | MEDICAID | C005 | 01 | TRICARE WEST | OTHER | 8T142WA | 01 | MN | BCBSMN | OTHER | HP22430 | 01 | HEALTHPARTNERS | OTHER | CN1040796006 | 01 | PREFERREDONE | OTHER | 01-15943 | 01 | MEDICA | OTHER |