Provider Demographics
NPI:1316932999
Name:MOGCK, ERIC PATRICK (MPT)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:PATRICK
Last Name:MOGCK
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:82 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:PA
Practice Address - Zip Code:19311-1140
Practice Address - Country:US
Practice Address - Phone:610-268-5333
Practice Address - Fax:610-268-5331
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT015895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP01480137OtherRR MEDICARE
PAM01424171OtherBCBS
PAP01480137OtherRR MEDICARE