Basic Information
| Provider Information | |||||||||
| NPI: | 1871114371 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MICHAEL | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19638 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949638 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 N 1ST ST STE D-319 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627023757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175458863 | ||||||||
| FaxNumber: | 2175459752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2020 | ||||||||
| LastUpdateDate: | 05/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 125075943 | IL | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.