Provider Demographics
NPI:1578571386
Name:CORCORAN, MICHAEL JOHN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:CORCORAN
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 1:400 SOUTH KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915
Mailing Address - Country:US
Mailing Address - Phone:815-928-8050
Mailing Address - Fax:800-505-2218
Practice Address - Street 1:400 SOUTH KENNEDY DR
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915
Practice Address - Country:US
Practice Address - Phone:815-928-8050
Practice Address - Fax:800-505-2218
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-95825207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-95825Medicaid
IL036-95825Medicaid