Provider Demographics
NPI:1194817767
Name:ANDERSON, ROGER CHARLES JR (PT)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:CHARLES
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38250 FAIRWAY COURT
Mailing Address - Street 2:#70
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038
Mailing Address - Country:US
Mailing Address - Phone:586-263-3770
Mailing Address - Fax:
Practice Address - Street 1:21700 NORTHWESTERN HWY STE 900
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4906
Practice Address - Country:US
Practice Address - Phone:248-556-9106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004487225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist