Provider Demographics
NPI:1528064581
Name:HISER, ROGER ALAN (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:ALAN
Last Name:HISER
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 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:150 GENTILLY BLVD
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-8522
Practice Address - Country:US
Practice Address - Phone:470-490-6030
Practice Address - Fax:470-490-6029
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA48899207RH0002X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000882725AMedicaid
GA11BDRVCMedicare ID - Type Unspecified
GA000882725AMedicaid