Provider Demographics
NPI:1255567574
Name:WILLIS, MICHELLE DIANNE (DO)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIANNE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12151 REGENCY PKWY STE 155
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-7644
Mailing Address - Country:US
Mailing Address - Phone:847-506-4400
Mailing Address - Fax:
Practice Address - Street 1:12151 REGENCY PKWY STE 155
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-7644
Practice Address - Country:US
Practice Address - Phone:847-506-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036130518207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036130518Medicaid
IL036130518Medicaid
ILP01297235OtherMEDICARE RR (INDIVIDUAL)
ILCH3246OtherMEDICARE RR (GROUP)