Provider Demographics
NPI:1356349815
Name:MIGLIORE, MICHELLE ANN (DO)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ANN
Last Name:MIGLIORE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:ANN
Other - Last Name:WYSONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:50965 BRIARWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-9779
Mailing Address - Country:US
Mailing Address - Phone:574-276-0857
Mailing Address - Fax:855-540-2473
Practice Address - Street 1:3371 W CLEVELAND ROAD EXT
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-9780
Practice Address - Country:US
Practice Address - Phone:574-218-6700
Practice Address - Fax:855-540-2473
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2025-05-14
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
IN02001135207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300098320Medicaid
IN200132430Medicaid
IN216440AMedicare ID - Type Unspecified