Provider Demographics
NPI:1154371581
Name:CORRELL, WILLIAM T (DO)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:T
Last Name:CORRELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1919 LAKE AVE STE 106
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-7830
Practice Address - Country:US
Practice Address - Phone:574-335-5220
Practice Address - Fax:574-335-0859
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014163DO207P00000X
MI5101014163207Q00000X
IN02007492A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300082849Medicaid
MI4849184Medicaid
MI4849193Medicaid
MI1022813OtherMHP HAN INDIVIDUAL
MI4963714Medicaid
MI080D410020OtherBDBSM COM BLUE
MI4849166Medicaid
MI1022851OtherMHP HAN GROUP
MI4849166Medicaid
MI0E06239090Medicare ID - Type Unspecified