Provider Demographics
NPI:1083055487
Name:RICHARD, MICHELE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:RICHARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST STE 1156
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3852
Mailing Address - Country:US
Mailing Address - Phone:312-563-2762
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 1156
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3852
Practice Address - Country:US
Practice Address - Phone:312-563-2762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-13
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1529532086S0129X
VA01160316212086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery