Provider Demographics
NPI:1972678548
Name:CALHOUN, MICHELLE BONITA (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:BONITA
Last Name:CALHOUN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:BONITA
Other - Last Name:CALHOUN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:27207 LAHSER RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-2168
Mailing Address - Country:US
Mailing Address - Phone:248-967-3200
Mailing Address - Fax:248-967-1387
Practice Address - Street 1:27207 LAHSER RD
Practice Address - Street 2:SUITE 250
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-2168
Practice Address - Country:US
Practice Address - Phone:248-967-3200
Practice Address - Fax:248-967-1387
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012320207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI56310495OtherBCBS PROVIDER NUMBER
MI471738075OtherTAX ID
MI5633229OtherBCBSM PIN
MIOP46640OtherGROUP PTAN
MI4546506-11Medicaid
MI5101012320OtherMEDICAL LICENSE
MIP46640001OtherPROVIDER PTAN
MI4546506-11Medicaid
MI20-8934350OtherTAX ID