Provider Demographics
NPI:1780830158
Name:ANGELINE, MICHAEL EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:ANGELINE
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 1:3524 E MILWAUKEE ST
Mailing Address - Street 2:MERCY CLINIC EAST
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-1626
Mailing Address - Country:US
Mailing Address - Phone:608-756-7100
Mailing Address - Fax:
Practice Address - Street 1:61 EMERALD PL
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:NY
Practice Address - Zip Code:12775-6049
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-17
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY260171207XX0005X, 207X00000X
WI57477-20207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1780830158Medicaid