Provider Demographics
NPI:1740321611
Name:EDWARDS, ROGER CHARLES (MSPT)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:CHARLES
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-1932
Mailing Address - Fax:630-928-5032
Practice Address - Street 1:1801 W MAUMEE ST
Practice Address - Street 2:STE 125
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1291
Practice Address - Country:US
Practice Address - Phone:517-264-6141
Practice Address - Fax:517-263-5786
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013463225100000X
MI5501017546225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist