Provider Demographics
NPI:1396843074
Name:FOGLESONG, MARY JO (MSPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:FOGLESONG
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JO
Other - Last Name:MASSAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:68 CONSUMER CENTER DR
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-2667
Practice Address - Country:US
Practice Address - Phone:740-773-6001
Practice Address - Fax:740-773-6007
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT 10795225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH300840OtherMEDICARE