Healthcare Provider Details

I. General information

NPI: 1306806278
Provider Name (Legal Business Name): KELLY NICOLE MICHELSON MD MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611-2605
US

IV. Provider business mailing address

225 E CHICAGO AVE
CHICAGO IL
60611-2605
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number036-104599
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: