Provider Demographics
NPI:1366702953
Name:OLIPHANT, MICHAEL (LAC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:OLIPHANT
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4770 N LINCOLN AVE STE 212
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2092
Mailing Address - Country:US
Mailing Address - Phone:312-869-9654
Mailing Address - Fax:
Practice Address - Street 1:4770 N LINCOLN AVE STE 212
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2092
Practice Address - Country:US
Practice Address - Phone:312-869-9654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-17
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000983171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist