Provider Demographics
NPI:1770588287
Name:DEHAAN, MICHAEL R (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:DEHAAN
Suffix:
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 1:2160 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-216-9000
Mailing Address - Fax:
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1634
Practice Address - Country:US
Practice Address - Phone:708-327-1540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073579208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360735792Medicaid
IL0001635157OtherBCBS PROVIDER NO.
ILP00213432OtherRRMC
ILP00213432OtherRRMC
IL0001635157OtherBCBS PROVIDER NO.
ILK17419Medicare PIN
IL0360735792Medicaid