Provider Demographics
NPI:1336138122
Name:COLEN, MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:COLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:WEIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-2290
Mailing Address - Country:US
Mailing Address - Phone:217-243-7700
Mailing Address - Fax:217-788-4611
Practice Address - Street 1:800 W STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-2290
Practice Address - Country:US
Practice Address - Phone:217-243-7700
Practice Address - Fax:217-788-4611
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000160621207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200122604Medicaid
MOI49721Medicare UPIN
MO938861740Medicare PIN