Provider Demographics
NPI:1366407769
Name:PHELPS, MICHAEL H (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:PHELPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3844 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:812-949-5482
Mailing Address - Fax:812-949-5966
Practice Address - Street 1:5300 STATE ROAD 64
Practice Address - Street 2:SUITE 101
Practice Address - City:GEORGETOWN
Practice Address - State:IN
Practice Address - Zip Code:47122-9178
Practice Address - Country:US
Practice Address - Phone:812-923-4200
Practice Address - Fax:812-949-5966
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047317A207R00000X
KY31429207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200139960Medicaid
G60384Medicare UPIN
IN200139960Medicaid