Provider Demographics
NPI:1366485005
Name:MICHELENA, MIA (DO)
Entity Type:Individual
Prefix:DR
First Name:MIA
Middle Name:
Last Name:MICHELENA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MIA
Other - Middle Name:F
Other - Last Name:WIMBERLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1775 DEMPSTER ST
Mailing Address - Street 2:RM E592B
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1143
Mailing Address - Country:US
Mailing Address - Phone:517-913-3810
Mailing Address - Fax:517-913-3811
Practice Address - Street 1:1540 LAKE LANSING RD
Practice Address - Street 2:STE 102
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3756
Practice Address - Country:US
Practice Address - Phone:517-913-3810
Practice Address - Fax:517-913-3811
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015690207R00000X
IL036149453207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7419836OtherAETNA
MI1022116OtherMCLAREN HEALTH PLAN-COMMERCIAL
MI1153311825OtherBLUE CROSS BLUE SHIELD
MI200000002785OtherPHP
MI200000002785OtherPHP FAMILYCARE
MIM21440049OtherMEDICARE ADVANTAGE
MI1022116OtherMCLAREN HEALTH PLAN-MEDICAID
MI1022116OtherMCLAREN HEALTH ADVANTAGE
MI1153311825OtherBLUE CARE NETWORK
MI4849578Medicaid
MIP00338685OtherRAILROAD MEDICARE
MI4849578Medicaid
MI1022116OtherMCLAREN HEALTH PLAN-COMMERCIAL