MEDICARE: MARKIA PRUITT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician

General Provider Information

NPI Number	:	1205288065
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARKIA PRUITT

Provider Business Mailing Address
First Line	:	615 DELAWARE ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49507-1229
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	615 DELAWARE ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49507-1229
Country	:	US
Telephone Number	:	616-419-6772
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2016
Last Update Date	:	07/05/2016

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Directions to “ MARKIA PRUITT ” Practice Location

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