Provider Demographics
NPI:1598872160
Name:MICHAEL, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:8780 W GOLF
Mailing Address - Street 2:SUITE 304
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714
Mailing Address - Country:US
Mailing Address - Phone:847-297-8900
Mailing Address - Fax:847-297-8926
Practice Address - Street 1:820 E TERRA COTTA AVE STE 247
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3655
Practice Address - Country:US
Practice Address - Phone:815-788-1000
Practice Address - Fax:815-788-2790
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036088212207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360882121Medicaid
IL0360882122OtherMEDICAID RETINALYSIS
IL05626127OtherBLUE CROSS BLUE SHIELD GP
ILDA3012OtherRAILROAD MEDICARE GROUP
IL180041333OtherRAILROAD MEDICARE
IL036088212OtherLICENSE NUMBER
IL05626127OtherBLUE CROSS BLUE SHIELD GP
IL241342001Medicare PIN
IL241343001Medicare PIN