Healthcare Provider Details

I. General information

NPI: 1376359760
Provider Name (Legal Business Name): ZANE ELGOGARI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7450 W 63RD ST
SUMMIT IL
60501-1816
US

IV. Provider business mailing address

7450 W 63RD ST
SUMMIT IL
60501-1816
US

V. Phone/Fax

Practice location:
  • Phone: 708-458-0757
  • Fax: 708-458-3784
Mailing address:
  • Phone: 708-458-0757
  • Fax: 708-458-3784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1228476
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: