Provider Demographics
NPI:1063446318
Name:FOGO, SHANE C (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:C
Last Name:FOGO
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 1:701 LEE ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-4539
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:105 S MAJOR ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:IL
Practice Address - Zip Code:61530-1246
Practice Address - Country:US
Practice Address - Phone:309-467-4691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111674207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111674Medicaid
IL10215111OtherBCBS TCH
IL5715395OtherBCBS HPT
IL5715395OtherBCBS HPT
IL10215111OtherBCBS TCH
ILK13837Medicare ID - Type UnspecifiedMEDICARE PIN HPT
ILK28868Medicare ID - Type UnspecifiedMEDICARE PIN TCH