Provider Demographics
NPI:1417246018
Name:STAR, MICHAEL J
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:STAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:J
Other - Last Name:STAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3245 HEALTH DR.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-3245
Mailing Address - Country:US
Mailing Address - Phone:547-647-1840
Mailing Address - Fax:
Practice Address - Street 1:615 N MICHIGAN ST
Practice Address - Street 2:1ST FL HOSPITALIST STE
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1033
Practice Address - Country:US
Practice Address - Phone:574-647-3050
Practice Address - Fax:574-647-1094
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01075143A2084N0400X
CODR.00571312084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300055663Medicaid
IN201305460Medicaid
IN262210015Medicare PIN