Provider Demographics
NPI:1215967294
Name:FAGERBURG, RODGER E (MD)
Entity type:Individual
Prefix:
First Name:RODGER
Middle Name:E
Last Name:FAGERBURG
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 1:743 JEFFERSON AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18510-1636
Mailing Address - Country:US
Mailing Address - Phone:570-342-5253
Mailing Address - Fax:570-342-6038
Practice Address - Street 1:743 JEFFERSON AVE STE 104
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1636
Practice Address - Country:US
Practice Address - Phone:570-342-5253
Practice Address - Fax:570-342-6038
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019917E207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007992800003Medicaid
C30265Medicare UPIN
PA106125Medicare PIN