Provider Demographics
NPI:1194721936
Name:MULLIGAN, MICHELLE P (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:P
Last Name:MULLIGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 STATE ROUTE 162
Mailing Address - Street 2:BOX 215
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062
Mailing Address - Country:US
Mailing Address - Phone:618-391-6495
Mailing Address - Fax:
Practice Address - Street 1:3417 ANDERSON HEALTHCARE DR STE 200
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-7784
Practice Address - Country:US
Practice Address - Phone:618-288-8500
Practice Address - Fax:618-288-8501
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081019207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0107339OtherUNITED HEALTHCARE
IL080021120OtherRR MEDICARE
N8565OtherGROUP HEALTH PLAN
IL4622029OtherADMINISTAR
IL036081019Medicaid
180420OtherHEALTHLINK
180420OtherHEALTHLINK
IL924650Medicare PIN
180420OtherHEALTHLINK