Provider Demographics
NPI:1477604791
Name:ALEXANDRE, MICHELLE J (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:ALEXANDRE
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 1:50 S B B KING BLVD # 100
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2626
Mailing Address - Country:US
Mailing Address - Phone:901-436-1381
Mailing Address - Fax:
Practice Address - Street 1:808 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-3744
Practice Address - Country:US
Practice Address - Phone:708-865-0663
Practice Address - Fax:708-345-9676
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100953207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100953Medicaid
IL1626842OtherBLUE CROSS BLUE SHIELD
ILH12332Medicare ID - Type Unspecified
ILH12332Medicare UPIN