Healthcare Provider Details

I. General information

NPI: 1134239064
Provider Name (Legal Business Name): MICHAEL CHARLES LIDDELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13105 SCHAVEY RD STE 4
DEWITT MI
48820-9014
US

IV. Provider business mailing address

13105 SCHAVEY RD STE 4
DEWITT MI
48820-9014
US

V. Phone/Fax

Practice location:
  • Phone: 517-668-0555
  • Fax: 517-668-0554
Mailing address:
  • Phone: 517-668-0555
  • Fax: 517-668-0554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101011829
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: