Provider Demographics
NPI:1285617456
Name:MINER, MICHELLE M (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:MINER
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:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:
Practice Address - Street 1:400 N 9TH ST FL 4
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5310
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-3971
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-106594208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036106594Medicaid
IL036106594Medicaid
H69998Medicare UPIN