Provider Demographics
NPI:1336138122
Name:COLEN, MICHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:COLEN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:WEIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 FOUNDERS LN STE 100
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-3924
Mailing Address - Country:US
Mailing Address - Phone:217-243-0300
Mailing Address - Fax:217-245-6775
Practice Address - Street 1:15 FOUNDERS LN STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3924
Practice Address - Country:US
Practice Address - Phone:217-243-0300
Practice Address - Fax:217-245-6775
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036120323207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036120323OtherIL MD LICENSE
MOI49721Medicare UPIN
MO938861740Medicare PIN