Healthcare Provider Details

I. General information

NPI: 1417977851
Provider Name (Legal Business Name): JORGE ALBERTO KURGANOFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 N KEDZIE BLVD
CHICAGO IL
60647-2634
US

IV. Provider business mailing address

2511 N KEDZIE BLVD
CHICAGO IL
60647-2634
US

V. Phone/Fax

Practice location:
  • Phone: 773-292-2700
  • Fax: 773-292-1536
Mailing address:
  • Phone: 773-292-2700
  • Fax: 773-292-1536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number03608383801
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: