Provider Demographics
NPI:1417977851
Name:KURGANOFF, JORGE ALBERTO (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:ALBERTO
Last Name:KURGANOFF
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 1:2511 N KEDZIE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2634
Mailing Address - Country:US
Mailing Address - Phone:773-292-2700
Mailing Address - Fax:773-292-1536
Practice Address - Street 1:2511 N KEDZIE BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2634
Practice Address - Country:US
Practice Address - Phone:773-292-2700
Practice Address - Fax:773-292-1536
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03608383801207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036083831Medicaid
IL507900OtherMEDICARE
K44405Medicare PIN
F62748Medicare UPIN