Provider Demographics
NPI:1306814413
Name:DEERY, MICHAEL F (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:F
Last Name:DEERY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:707 E CEDAR ST
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:921 N LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:CULVER
Practice Address - State:IN
Practice Address - Zip Code:46511
Practice Address - Country:US
Practice Address - Phone:574-842-3327
Practice Address - Fax:574-842-4330
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01020772A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000733193OtherBCBS
IN000000878027OtherBCBS
IN10017329CMedicaid
B29144Medicare UPIN
IN10017329CMedicaid
INP01013527Medicare PIN
INM400061830Medicare PIN
ININ1933002Medicare PIN