Provider Demographics
NPI:1205965936
Name:SERGEANT, MICHAEL JOHN SR (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:SERGEANT
Suffix:SR
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 1:475 BROWN BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2325
Mailing Address - Country:US
Mailing Address - Phone:815-939-7421
Mailing Address - Fax:
Practice Address - Street 1:475 BROWN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2325
Practice Address - Country:US
Practice Address - Phone:815-939-7421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360577042084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057704Medicaid
C45861Medicare UPIN
ILIL 7306Medicare PIN