Provider Demographics
NPI:1851383301
Name:ADAMS, MICHAEL C (ME)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:ADAMS
Suffix:
Gender:M
Credentials:ME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2166 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4700
Mailing Address - Country:US
Mailing Address - Phone:618-452-3301
Mailing Address - Fax:618-452-3312
Practice Address - Street 1:2166 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4700
Practice Address - Country:US
Practice Address - Phone:618-452-3301
Practice Address - Fax:618-452-3312
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093660207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093660OtherSTATE LICENSE NUMBER
ILK11155Medicare ID - Type Unspecified
IL036093660OtherSTATE LICENSE NUMBER