Provider Demographics
NPI:1255338554
Name:COULSON, MICHAEL D (DO)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:COULSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 KISH HOSPITAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-9602
Mailing Address - Country:US
Mailing Address - Phone:815-756-1521
Mailing Address - Fax:815-748-8395
Practice Address - Street 1:1 KISH HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9602
Practice Address - Country:US
Practice Address - Phone:815-756-1521
Practice Address - Fax:815-748-8395
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077834207LP2900X
IL036.077834207L00000X
IL336.040926207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077834Medicaid
IL050082135OtherRAILROAD MEDICARE
20104Medicare PIN
E18506Medicare UPIN
ILK03401Medicare PIN
IL050082135OtherRAILROAD MEDICARE
ILE18506Medicare UPIN