=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619123114
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARGARET GROSS MICHELSON M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2008
-----------------------------------------------------
Last Update Date | 02/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 CENTRAL ST SUITE 800
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-1777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-570-2577
-----------------------------------------------------
Fax | 847-733-5424
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 CENTRAL ST SUITE 800
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-1777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-570-2577
-----------------------------------------------------
Fax | 847-733-5424
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 125054703
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0402X
-----------------------------------------------------
Taxonomy Name | Neurology with Special Qualifications in Child Neurology Physician
-----------------------------------------------------
License Number | 125054703
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084N0402X
-----------------------------------------------------
Taxonomy Name | Neurology with Special Qualifications in Child Neurology Physician
-----------------------------------------------------
License Number | 036131101
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------