Healthcare Provider Details

I. General information

NPI: 1134769938
Provider Name (Legal Business Name): MICAH MCKEE MS, ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 GEESLIN RD
GRENADA MS
38901-8647
US

IV. Provider business mailing address

416 GEESLIN RD
GRENADA MS
38901-8647
US

V. Phone/Fax

Practice location:
  • Phone: 601-513-1231
  • Fax:
Mailing address:
  • Phone: 601-513-1231
  • Fax: 601-513-1231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberAT0894
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: