Basic Information
| Provider Information | |||||||||
| NPI: | 1437269545 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEO | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SEO | ||||||||
| OtherFirstName: | MEEIL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 199 W RAND RD | ||||||||
| Address2: | |||||||||
| City: | MT PROSPECT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600561151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476185450 | ||||||||
| FaxNumber: | 8476185459 | ||||||||
| Practice Location | |||||||||
| Address1: | 199 W RAND RD | ||||||||
| Address2: | |||||||||
| City: | MT PROSPECT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600561151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476185450 | ||||||||
| FaxNumber: | 8476185459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036090073 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0004532435 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 036090073 | 05 | IL | MEDICAID |