Basic Information
| Provider Information | |||||||||
| NPI: | 1245279181 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOGOLUB | ||||||||
| FirstName: | DAVID | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3836 N TRIPP AVE | ||||||||
| Address2: | XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606413011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309414330 | ||||||||
| FaxNumber: | 6309414333 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | GRANITE CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620404701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187983000 | ||||||||
| FaxNumber: | 6187983885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.