Provider Demographics
NPI:1285891127
Name:VOGELZANG, KEVIN M (PT, ATC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:VOGELZANG
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 W BROADWAY ST STE C
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1825
Mailing Address - Country:US
Mailing Address - Phone:406-544-5679
Mailing Address - Fax:
Practice Address - Street 1:1900 W BROADWAY ST STE C
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1825
Practice Address - Country:US
Practice Address - Phone:406-544-5679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1576225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0052326Medicaid
MT0000050832Medicare PIN