Provider Demographics
NPI:1306894647
Name:ROGUE ENDOCRINOLOGY AND METABOLIC CLINIC
Entity type:Organization
Organization Name:ROGUE ENDOCRINOLOGY AND METABOLIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARISSA
Authorized Official - Middle Name:K
Authorized Official - Last Name:STULTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-773-9772
Mailing Address - Street 1:3144 STATE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8450
Mailing Address - Country:US
Mailing Address - Phone:541-772-9355
Mailing Address - Fax:541-772-6355
Practice Address - Street 1:3144 STATE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8450
Practice Address - Country:US
Practice Address - Phone:541-772-9355
Practice Address - Fax:541-772-6355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR134817Medicare PIN