Provider Demographics
NPI:1215017744
Name:ROGERS, GLENN ALVIN (MD)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:ALVIN
Last Name:ROGERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12459 US 22 AND 3
Mailing Address - Street 2:
Mailing Address - City:SABINA
Mailing Address - State:OH
Mailing Address - Zip Code:45169
Mailing Address - Country:US
Mailing Address - Phone:937-584-2459
Mailing Address - Fax:937-584-4941
Practice Address - Street 1:12459 US 22 AND 3
Practice Address - Street 2:
Practice Address - City:SABINA
Practice Address - State:OH
Practice Address - Zip Code:45169
Practice Address - Country:US
Practice Address - Phone:937-584-2459
Practice Address - Fax:937-584-4941
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076945R174400000X
OH35076945207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2198527Medicaid
OH2198527Medicaid
OH6035901Medicare PIN
OHH08665Medicare UPIN