Provider Demographics
NPI:1912991688
Name:MICHELOTTI, MICHAEL C (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:MICHELOTTI
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 1:2350 N ROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-3600
Mailing Address - Country:US
Mailing Address - Phone:815-963-3426
Mailing Address - Fax:815-963-3428
Practice Address - Street 1:2350 N ROCKTON AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3600
Practice Address - Country:US
Practice Address - Phone:815-963-3426
Practice Address - Fax:815-963-3428
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03668258208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036068258Medicaid
IL204672Medicare ID - Type Unspecified
C41453Medicare UPIN
IL036068258Medicaid