Provider Demographics
NPI:1376588525
Name:MELLETT, MICHELE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:MARIE
Last Name:MELLETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 W WELLINGTON AVE
Mailing Address - Street 2:TRAUMA OFFICE, 4318
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5147
Mailing Address - Country:US
Mailing Address - Phone:773-296-7033
Mailing Address - Fax:773-296-7199
Practice Address - Street 1:836 W WELLINGTON AVE
Practice Address - Street 2:TRAUMA OFFICE, 4318
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:773-296-7033
Practice Address - Fax:773-296-7199
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Not Answered2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE93154Medicare UPIN
IL20054683Medicare ID - Type Unspecified