Provider Demographics
NPI:1922107952
Name:EARLEY, MICHAEL WILLIAM (M D)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:EARLEY
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3623 W CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-3934
Mailing Address - Country:US
Mailing Address - Phone:773-722-6171
Mailing Address - Fax:773-722-7913
Practice Address - Street 1:3623 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-3934
Practice Address - Country:US
Practice Address - Phone:773-722-6171
Practice Address - Fax:773-722-7913
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067635207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067635Medicaid
ILC44484Medicare UPIN
IL799030Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER