Provider Demographics
NPI:1871598813
Name:KOELLERMEIER, MICHELLE M (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:M
Last Name:KOELLERMEIER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5485 W GRANDE MARKET DR STE C
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8430
Mailing Address - Country:US
Mailing Address - Phone:920-729-7105
Mailing Address - Fax:
Practice Address - Street 1:200 THEDA CLARK MEDICAL PLZ
Practice Address - Street 2:STE 130
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2790
Practice Address - Country:US
Practice Address - Phone:920-729-7105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46159207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34444300Medicaid
WI34444300Medicaid