Healthcare Provider Details

I. General information

NPI: 1528089679
Provider Name (Legal Business Name): SOLOMON KNICELY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 N MACOMB ST
MONROE MI
48162
US

IV. Provider business mailing address

3500 15 MILE RD
STERLING HEIGHTS MI
48310-5353
US

V. Phone/Fax

Practice location:
  • Phone: 734-240-4435
  • Fax:
Mailing address:
  • Phone: 586-977-6212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101015716
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number5101015716
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: