Basic Information
| Provider Information | |||||||||
| NPI: | 1396843074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOGLESONG | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MASSAY | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | JO | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 68 CONSUMER CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456012667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407736001 | ||||||||
| FaxNumber: | 7407736007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 04/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 10795 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | H300840 | 01 | OH | MEDICARE | OTHER |