Basic Information
| Provider Information | |||||||||
| NPI: | 1730297789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOGAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2350 ROYAL BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479315300 | ||||||||
| FaxNumber: | 8479319072 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 ROYAL BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479315300 | ||||||||
| FaxNumber: | 8479319072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 036090418 | IL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | 036090418 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200023140 | 01 | RR MEDICARE PROV | OTHER | 207906 | 01 | MEDICARE GRP MCHENRY | OTHER | 208821 | 01 | MEDICARE GRP KANE | OTHER | CG2631 | 01 | RR MEDICARE GRP MCH | OTHER | 036090418 | 05 | IL | MEDICAID | CE6001 | 01 | RR MEDICARE GRP KANE | OTHER |