MEDICARE: MRS. ROSANNE OGGOIAN D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	2080A0000X	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04926673	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1043201387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ROSANNE OGGOIAN D.O.

Provider Business Mailing Address
First Line	:	721 N MCKINLEY RD
Second Line	:	FIRST FLOOR
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-1849
Country	:	US
Telephone Number	:	847-735-9330
Fax Number	:	847-735-9301

Provider Business Practice Location Address
First Line	:	50 S MILWAUKEE AVE
Second Line	:	SUITE 203
City	:	LAKE VILLA
State	:	IL
Zip	:	60046-9471
Country	:	US
Telephone Number	:	847-356-5747
Fax Number	:	847-356-5886

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	07/08/2007

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