Provider Demographics
NPI:1639163173
Name:MICHELOTTI, JOSEPH N (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:N
Last Name:MICHELOTTI
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 1:351 SHARON DR
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-3412
Mailing Address - Country:US
Mailing Address - Phone:847-776-1200
Mailing Address - Fax:847-776-9400
Practice Address - Street 1:350 S 8TH ST
Practice Address - Street 2:
Practice Address - City:WEST DUNDEE
Practice Address - State:IL
Practice Address - Zip Code:60118-2248
Practice Address - Country:US
Practice Address - Phone:847-776-1200
Practice Address - Fax:847-776-9400
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03655132208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036055132Medicaid
IL674000Medicare ID - Type Unspecified
IL204672Medicare ID - Type Unspecified
IL036055132Medicaid