Provider Demographics
NPI:1033373907
Name:KOUIMELIS, MICHAEL DEMETRIOS (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DEMETRIOS
Last Name:KOUIMELIS
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 1:9951 ROCK CUT XING
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-1999
Mailing Address - Country:US
Mailing Address - Phone:815-639-8500
Mailing Address - Fax:815-639-8501
Practice Address - Street 1:9951 ROCK CUT XING
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-1999
Practice Address - Country:US
Practice Address - Phone:815-639-8500
Practice Address - Fax:815-639-8501
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121741Medicaid
IL553180OtherMEDICARE GROUP #
IL834370OtherMEDICARE GROUP #
IL553180OtherMEDICARE GROUP #
IL5531800011Medicare PIN