Provider Demographics
NPI:1417953316
Name:MULLIGAN, MICHAEL E (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:MULLIGAN
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 1:3 JUNCTION DR W
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-2916
Mailing Address - Country:US
Mailing Address - Phone:618-288-5088
Mailing Address - Fax:
Practice Address - Street 1:3 JUNCTION DR W
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-2916
Practice Address - Country:US
Practice Address - Phone:618-288-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078912207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
102922OtherHEALTHLINK
IL4622029OtherADMINISTAR
IL6015373OtherBCBS
IL036078712Medicaid
IL080021119OtherRR MEDICARE
4322029OtherUNITED HEALTHCARE
N4862OtherGROUP HEALTH PLAN
IL4622029OtherADMINISTAR
IL036078712Medicaid
IL4622029OtherADMINISTAR