Healthcare Provider Details

I. General information

NPI: 1528614781
Provider Name (Legal Business Name): ALEX FOGT DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2019
Last Update Date: 01/02/2023
Certification Date: 01/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 N ESTRELLA PKWY STE A1
GOODYEAR AZ
85338-2885
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 623-322-0654
  • Fax: 623-322-0664
Mailing address:
  • Phone: 866-370-8206
  • Fax: 517-435-3670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-32055
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT210002132
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05014613A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT018257
License Number StateOH
# 5
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP011725T
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: