Provider Demographics
NPI:1821439225
Name:CARMICHAEL, NICOLE MARY (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARY
Last Name:CARMICHAEL
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19635
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9635
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-757-6519
Practice Address - Street 1:415 N 9TH ST
Practice Address - Street 2:SUITE 4W64
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5303
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-757-6519
Is Sole Proprietor?:No
Enumeration Date:2013-07-13
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-139643208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036139643Medicaid
IL036139643Medicaid