Provider Demographics
NPI:1124382403
Name:COLLINS, MICHELE NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:NICOLE
Last Name:COLLINS
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 1:707 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2054
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:
Practice Address - Street 1:611 E DOUGLAS RD STE 406
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545
Practice Address - Country:US
Practice Address - Phone:574-335-6580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-01
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036139645207Q00000X
IN01073777B207Q00000X
IN11017396A207Q00000X
IN01073777A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201170290Medicaid
ILF400330742OtherMEDICARE PTAN INDIVIDUAL
IL592050OtherMEDICARE PTAN GROUP