Provider Demographics
NPI:1821352915
Name:FONG, ROGER (MPT)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:
Last Name:FONG
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 E 53RD ST STE 814
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4572
Mailing Address - Country:US
Mailing Address - Phone:312-403-1853
Mailing Address - Fax:773-947-0084
Practice Address - Street 1:4835 S LANGLEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-1515
Practice Address - Country:US
Practice Address - Phone:312-403-1853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-03
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001289171100000X
IL070013559225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturist