Provider Demographics
NPI:1992763494
Name:MCQUILLEN, MICHAEL WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:MCQUILLEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2700 STANLEY GAULT PKWY
Mailing Address - Street 2:SUITE 129
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5132
Mailing Address - Country:US
Mailing Address - Phone:502-253-4917
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:4001 KRESGE WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4640
Practice Address - Country:US
Practice Address - Phone:502-897-6579
Practice Address - Fax:502-897-2725
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2020-12-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY39813207X00000X, 207XX0004X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64125750Medicaid
KYP00326690Medicare PIN
KY1282011Medicare PIN
KYI33976Medicare UPIN
KY64125750Medicaid