Provider Demographics
NPI:1235302878
Name:BOGERT, MARK WILLIAM (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:BOGERT
Suffix:
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 1:4729 AMBERGLOW DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-8846
Mailing Address - Country:US
Mailing Address - Phone:701-426-7095
Mailing Address - Fax:701-250-0182
Practice Address - Street 1:602 ASH AVE
Practice Address - Street 2:
Practice Address - City:GLEN ULLIN
Practice Address - State:ND
Practice Address - Zip Code:58632-0065
Practice Address - Country:US
Practice Address - Phone:701-348-9175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND 0534225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54373Medicaid
ND25559OtherBLUE CROSS/BLUE SHIELD
ND25559OtherBLUE CROSS/BLUE SHIELD