Healthcare Provider Details

I. General information

NPI: 1023377736
Provider Name (Legal Business Name): PAUL KOGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 04/21/2025
Certification Date: 07/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 CROSS ST DIV SURG UROLOGY, STE 180
SHILOH IL
62269-2914
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-8200
  • Fax: 833-210-5713
Mailing address:
  • Phone: 314-362-8200
  • Fax: 833-210-5713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036156535
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: