Provider Demographics
NPI:1851496764
Name:HOGAN, MARY ELIZABETH (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:HOGAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:DOEDERLEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:917 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-3347
Mailing Address - Country:US
Mailing Address - Phone:630-932-9663
Mailing Address - Fax:630-620-1901
Practice Address - Street 1:917 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-3347
Practice Address - Country:US
Practice Address - Phone:630-932-9663
Practice Address - Fax:630-620-1901
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038003995111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0002205085OtherBCBS
ILPA038003995Medicaid
IL667690Medicare ID - Type Unspecified
ILPA038003995Medicaid