Provider Demographics
NPI:1518163401
Name:LAL, ANN KELLOGG (MD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:KELLOGG
Last Name:LAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:
Other - Last Name:KELLOGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:LOYOLA OUTPATIENT CENTER
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-216-9000
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:LOYOLA OUTPATIENT CENTER
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126984207VM0101X
IL036.126984207V00000X
MN50877207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN160002896Medicare PIN
MNENROLLEDMedicaid
IAENROLLEDMedicaid