Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 216301 | MA |
Y | 2080P0208X | Pediatric Infectious Diseases | MD13482 | RI |
NPI | 1386634756 |
---|---|
Provider Name | Dr. Ian Charles Michelow |
First Address | Providence, RI 02903-4923 |
Second Address | Providence, RI 02903-4923 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/10/2005 |
Last Update Date | 18/01/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2026091 | (05) | MA |
468557 | TUFTS HEALTH PLAN (01) | MA |
H99939 | (02) | |
J26918 | BCBS MA (01) | MA |
MD13482 | LICENSE (01) | RI |