Provider Demographics
NPI:1215983036
Name:MELLON, MICHAEL JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:MELLON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 E HUGHITT ST
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-2910
Mailing Address - Country:US
Mailing Address - Phone:906-774-2488
Mailing Address - Fax:906-774-2307
Practice Address - Street 1:208 E HUGHITT ST
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-2910
Practice Address - Country:US
Practice Address - Phone:906-774-2488
Practice Address - Fax:906-774-2307
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004916111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950B250030OtherBLUE CROSS BLUE SHIELD
MIP00093384OtherRAILROAD MEDICARE
MIB25003001Medicare ID - Type Unspecified
T32708Medicare UPIN