Healthcare Provider Details

I. General information

NPI: 1558619619
Provider Name (Legal Business Name): MICHELLE BUELOW R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 W FULTON ST STE 105
CHICAGO IL
60612-2345
US

IV. Provider business mailing address

2003 W FULTON ST STE 105
CHICAGO IL
60612-2345
US

V. Phone/Fax

Practice location:
  • Phone: 312-850-3438
  • Fax:
Mailing address:
  • Phone: 312-850-3438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.005615
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: