Provider Demographics
NPI:1295876803
Name:ROGERS, BRYAN MICHAEL (MPT)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:MICHAEL
Last Name:ROGERS
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 1:615 S POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-5853
Mailing Address - Country:US
Mailing Address - Phone:336-724-2656
Mailing Address - Fax:
Practice Address - Street 1:737 PENN ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-5317
Practice Address - Country:US
Practice Address - Phone:336-719-7129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist