Provider Demographics
NPI:1053364042
Name:KOGAN, NEPHTALI (MD)
Entity type:Individual
Prefix:
First Name:NEPHTALI
Middle Name:
Last Name:KOGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BIESTERFIELD RD STE G01
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3372
Mailing Address - Country:US
Mailing Address - Phone:847-981-3680
Mailing Address - Fax:
Practice Address - Street 1:800 BIESTERFIELD RD STE G01
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3372
Practice Address - Country:US
Practice Address - Phone:847-981-3680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078655207RC0000X
IL036-078655207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01013369OtherRRMC PTAN
IL1720371669OtherNPI GROUP PRACTICE
ILIL6304019OtherMEDICARE PTAN LOC 16
ILIL6305019OtherMEDICARE PTAN LOC 15
ILF76632Medicare UPIN