Provider Demographics
NPI:1134675358
Name:BEMPONG, KOJO
Entity type:Individual
Prefix:
First Name:KOJO
Middle Name:
Last Name:BEMPONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 S CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-1707
Mailing Address - Country:US
Mailing Address - Phone:773-571-1988
Mailing Address - Fax:
Practice Address - Street 1:AHCMG ANESTHESIOLOGY
Practice Address - Street 2:4025 NORTH 92ND STREET
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53022
Practice Address - Country:US
Practice Address - Phone:414-358-5431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI367H00000X
GA9223367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant