Provider Demographics
NPI:1063507127
Name:HOGAN, MITCHELE (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELE
Middle Name:
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 1:826 S MILLER ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4207
Mailing Address - Country:US
Mailing Address - Phone:312-733-9010
Mailing Address - Fax:
Practice Address - Street 1:822 S MILLER ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-4207
Practice Address - Country:US
Practice Address - Phone:312-733-9010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336.027529 036.06299207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062994Medicaid
ILK09516Medicare ID - Type Unspecified
IL036062994Medicaid