Basic Information
| Provider Information | |||||||||
| NPI: | 1477604791 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALEXANDRE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 S B B KING BLVD # 100 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014361381 | ||||||||
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| Practice Location | |||||||||
| Address1: | 808 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601603744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088650663 | ||||||||
| FaxNumber: | 7083459676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036100953 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036100953 | 05 | IL | MEDICAID | 1626842 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |