Provider Demographics
NPI:1164577755
Name:MCCROHAN, MICHAEL B (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:MCCROHAN
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 1:1325 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2659
Mailing Address - Country:US
Mailing Address - Phone:708-579-3418
Mailing Address - Fax:708-579-3485
Practice Address - Street 1:1325 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2659
Practice Address - Country:US
Practice Address - Phone:708-579-3418
Practice Address - Fax:708-579-3485
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082736207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
L33559Medicare ID - Type Unspecified
G09274Medicare UPIN