Provider Demographics
NPI:1033134432
Name:HOGAN, MICHAEL LEO (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEO
Last Name:HOGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:3900 ST FRANCIS WAY STE 200
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4940
Practice Address - Country:US
Practice Address - Phone:765-775-2800
Practice Address - Fax:765-775-2831
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065848A207R00000X, 207RC0000X, 207RI0011X
NE28180207RC0000X
SD9306207RC0000X
IL36070321207RI0011X, 2085B0100X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000586631OtherANTHEM PROVIDER NUMBER
IL101 15504OtherB/C B/S OF ILLINOIS
IL03607032 1Medicaid
IN200917540Medicaid
GACB0709/060019665OtherRR MEDICARE GROUP ID#/PIN
IL36-2772589OtherEIN
IL36-2772589OtherEIN
IL101 15504OtherB/C B/S OF ILLINOIS
ILL26595Medicare PIN
IN142080ZZZMedicare PIN
IN815490IIIIMedicare PIN
INP00678470Medicare PIN
ILE96078Medicare UPIN
GACB0709/060019665OtherRR MEDICARE GROUP ID#/PIN