Provider Demographics
NPI:1174506190
Name:YU, MICHAEL NITHIPHAISAL (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:NITHIPHAISAL
Last Name:YU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT CH 17767
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60055-7767
Mailing Address - Country:US
Mailing Address - Phone:800-968-6866
Mailing Address - Fax:
Practice Address - Street 1:1 GENESYS PKWY
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8065
Practice Address - Country:US
Practice Address - Phone:810-606-6137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013110207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MY013110OtherBLUE CROSS BLUE SHIELD
MI4253184Medicaid
930109721OtherRAILROAD MEDICARE
MI4253175Medicaid
MI4253193Medicaid
MI4253193Medicaid
MIB56088069Medicare Oscar/Certification