Provider Demographics
NPI:1366422610
Name:ROLOGAS, STAVROS ANASTASIOS (PT)
Entity type:Individual
Prefix:
First Name:STAVROS
Middle Name:ANASTASIOS
Last Name:ROLOGAS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 UMBRA ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-4612
Mailing Address - Country:US
Mailing Address - Phone:443-838-1029
Mailing Address - Fax:410-522-0290
Practice Address - Street 1:808 S CONKLING ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-4354
Practice Address - Country:US
Practice Address - Phone:410-522-6978
Practice Address - Fax:410-522-0290
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17174225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD53443002OtherBLUE CROSS/BLUE SHIELD
MD423M609FMedicare ID - Type UnspecifiedMEDICARE ID #