Provider Demographics
NPI:1215044508
Name:DEBRE, MICHAEL W (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:W
Last Name:DEBRE
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 1:11600 S KEDZIE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MERRIONETTE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60803-6307
Mailing Address - Country:US
Mailing Address - Phone:708-684-6867
Mailing Address - Fax:
Practice Address - Street 1:11600 S KEDZIE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MERRIONETTE PARK
Practice Address - State:IL
Practice Address - Zip Code:60803-6307
Practice Address - Country:US
Practice Address - Phone:708-684-6867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053268207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36053268Medicaid
D13815Medicare UPIN
IL606500Medicare ID - Type Unspecified