Provider Demographics
NPI:1104704824
Name:ROGUE PHYSIO LLC
Entity type:Organization
Organization Name:ROGUE PHYSIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:PT DPT
Authorized Official - Phone:865-363-1222
Mailing Address - Street 1:564 OAK RIDGE TURNPIKE
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-7164
Mailing Address - Country:US
Mailing Address - Phone:865-213-2744
Mailing Address - Fax:865-315-7033
Practice Address - Street 1:564 OAK RIDGE TPKE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-7164
Practice Address - Country:US
Practice Address - Phone:865-213-2744
Practice Address - Fax:865-315-7033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-21
Last Update Date:2025-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty