Basic Information
| Provider Information | |||||||||
| NPI: | 1366407769 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHELPS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3844 RELIABLE PKWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606860001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129495482 | ||||||||
| FaxNumber: | 8129495966 | ||||||||
| Practice Location | |||||||||
| Address1: | 5300 STATE ROAD 64 | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GEORGETOWN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471229178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129234200 | ||||||||
| FaxNumber: | 8129495966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 06/04/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01047317A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 31429 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200139960 | 05 | IN | MEDICAID |