Healthcare Provider Details

I. General information

NPI: 1255277943
Provider Name (Legal Business Name): MR. MICHAEL AIDAN MULLARKEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

771 CHESTNUT RD
EAST LANSING MI
48824-3434
US

IV. Provider business mailing address

1025 EVERGREEN DR
LAKE FOREST IL
60045-4300
US

V. Phone/Fax

Practice location:
  • Phone: 847-977-9107
  • Fax:
Mailing address:
  • Phone: 847-977-9107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: