Healthcare Provider Details

I. General information

NPI: 1659552800
Provider Name (Legal Business Name): LAURENCE HOGSTROM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2007
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5131 N LINCOLN AVE
CHICAGO IL
60625-2585
US

IV. Provider business mailing address

5131 N LINCOLN AVE
CHICAGO IL
60625-2585
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-1515
  • Fax: 773-878-2036
Mailing address:
  • Phone: 773-878-1515
  • Fax: 773-878-2036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: