Provider Demographics
NPI:1164481859
Name:GHILEZAN, MICHAEL I (MD, PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:I
Last Name:GHILEZAN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:I
Other - Last Name:GHILEZAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:70 FULTON ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-2755
Practice Address - Country:US
Practice Address - Phone:248-338-0300
Practice Address - Fax:248-338-0663
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010799382085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI41719OtherHEALTH PLAN OF MICHIGAN
MI320F362430OtherBCBSM
MIP01013937OtherRAILROAD MEDICARE
MI01044465OtherHEALTH PLUS OF MICHIGAN THRU OAKLAND PHYSICIANS NETWORK SERVICES (OPNS)
MI7032547OtherCOFINITY
MI202490OtherUNITED HEALTHCARE COMMUNITY PLAN
MI7032547OtherAETNA
MI4535709Medicaid
MI7032547OtherAETNA THRU OAKLAND PHYSICIANS NETWORK SERVICES
MI320F362430OtherBCBSM
MIH93735Medicare UPIN
MI0F36243023Medicare PIN