Healthcare Provider Details

I. General information

NPI: 1548426158
Provider Name (Legal Business Name): BRIAN THOMAS MICHALSEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2008
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6998 REDANSA DR
ROCKFORD IL
61108-4378
US

IV. Provider business mailing address

601 JOHN STREET BOX 42
KALAMAZOO MI
49007
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-2000
  • Fax: 815-971-9620
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036126596
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-126596
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number5101027951
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101027951
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: