Provider Demographics
NPI:1386665081
Name:MULLANE, MICHAEL RUSSELL
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RUSSELL
Last Name:MULLANE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 BARTRAM RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-1885
Mailing Address - Country:US
Mailing Address - Phone:312-864-7194
Mailing Address - Fax:312-864-9002
Practice Address - Street 1:1900 W POLK ST
Practice Address - Street 2:ROOM 765
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3723
Practice Address - Country:US
Practice Address - Phone:312-864-7194
Practice Address - Fax:312-864-9002
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-068847207R00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D13670Medicare UPIN