Provider Demographics
NPI:1386634756
Name:MICHELOW, IAN CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:CHARLES
Last Name:MICHELOW
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 1:593 EDDY ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-8360
Mailing Address - Fax:401-444-5650
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-8360
Practice Address - Fax:401-444-5650
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216301208000000X
RIMD134822080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ26918OtherBCBS MA
RIMD13482OtherLICENSE
MA468557OtherTUFTS HEALTH PLAN
MA2026091Medicaid
RIMD13482OtherLICENSE
MAA36300Medicare ID - Type Unspecified