Provider Demographics
NPI:1841264454
Name:PRINCE, MICHELLE MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:MARIE
Last Name:PRINCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N 8TH ST DEPT OF
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62701-1041
Mailing Address - Country:US
Mailing Address - Phone:217-757-6535
Mailing Address - Fax:
Practice Address - Street 1:5153 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8785
Practice Address - Country:US
Practice Address - Phone:850-416-1575
Practice Address - Fax:850-416-1302
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHLT 3316207X00000X, 207XP3100X
IL036.131686207XP3100X
TXL6587207XP3100X
FLME143244207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1624231-05OtherMEDICAID CSHCN - ROT
TX8K8547OtherBCBS INDIVIDUAL #
TX1624231-04Medicaid
TX162423103OtherMEDICAID CSHCN
TX1624231-06Medicaid
TX8L11750Medicare PIN
TXTXB114373Medicare PIN
TX162423103OtherMEDICAID CSHCN