Healthcare Provider Details

I. General information

NPI: 1063507127
Provider Name (Legal Business Name): MITCHELE HOGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 06/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 S MILLER ST
CHICAGO IL
60607-4207
US

IV. Provider business mailing address

826 S MILLER ST
CHICAGO IL
60607-4207
US

V. Phone/Fax

Practice location:
  • Phone: 312-733-9010
  • Fax:
Mailing address:
  • Phone: 312-733-9010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number336.027529 036.06299
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: