Provider Demographics
NPI:1417326802
Name:FOGAL, MATTHEW STEPHEN (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STEPHEN
Last Name:FOGAL
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 1:4401 CAMPUS RIDGE DR STE 1000
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6125
Mailing Address - Country:US
Mailing Address - Phone:989-837-9100
Mailing Address - Fax:989-837-9105
Practice Address - Street 1:4401 CAMPUS RIDGE DR STE 1000
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6125
Practice Address - Country:US
Practice Address - Phone:989-837-9100
Practice Address - Fax:989-837-9105
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017397225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist