Basic Information
| Provider Information | |||||||||
| NPI: | 1558332718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOGULSKI | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | C | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0258894905 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 7926 PRESTON HWY STE 106 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402193848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029644357 | ||||||||
| FaxNumber: | 5029665948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02005420A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | M7997 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 200501860 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 53331 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5902650 | 05 | NC | MEDICAID |