Healthcare Provider Details

I. General information

NPI: 1669414900
Provider Name (Legal Business Name): GREGORY P BOGDONOFF M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21120 WASHINGTON PKWY
FRANKFORT IL
60423-3112
US

IV. Provider business mailing address

21120 WASHINGTON PKWY
FRANKFORT IL
60423-3112
US

V. Phone/Fax

Practice location:
  • Phone: 815-469-9750
  • Fax: 815-469-9752
Mailing address:
  • Phone: 815-469-9750
  • Fax: 815-469-9752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number036076482
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036076482
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: