MEDICARE: MR. CORY D ROGOTZKE DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5501016325	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0C80228	OTHER		BCBS

General Provider Information

NPI Number	:	1154768463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CORY D ROGOTZKE DPT

Provider Business Mailing Address
First Line	:	3073 SHIRLEY DR
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49201-7010
Country	:	US
Telephone Number	:	517-990-6211
Fax Number	:	517-990-6212

Provider Business Practice Location Address
First Line	:	2136 ROBINSON RD STE 1
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49203-3558
Country	:	US
Telephone Number	:	517-750-2540
Fax Number	:	517-990-6212

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2013
Last Update Date	:	02/10/2025

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