MEDICARE: MAKIKO OGINO-MCELLIGOTT PA-C

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	363A00000X	Physician Assistant	085-001932	IL

General Provider Information

NPI Number	:	1134121965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAKIKO OGINO-MCELLIGOTT PA-C

Provider Business Mailing Address
First Line	:	525 E CONGRESS PKWY
Second Line	:	100
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-6245
Country	:	US
Telephone Number	:	815-479-8020
Fax Number	:

Provider Business Practice Location Address
First Line	:	525 E CONGRESS PKWY
Second Line	:	100
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-6245
Country	:	US
Telephone Number	:	815-479-8020
Fax Number	:

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

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	01/07/2017

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