MEDICARE: MRS. MARY KAY KNOX

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	171M00000X	Case Manager/Care Coordinator	6802080184	MI

General Provider Information

NPI Number	:	1427485507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY KAY KNOX

Provider Business Mailing Address
First Line	:	22724 SAINT JOAN ST
Second Line	:
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48080-3867
Country	:	US
Telephone Number	:	248-330-4103
Fax Number	:	248-330-4103

Provider Business Practice Location Address
First Line	:	22724 SAINT JOAN ST
Second Line	:
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48080-3867
Country	:	US
Telephone Number	:	248-330-4103
Fax Number	:	248-330-4103

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

Provider Enumeration Date	:	10/03/2013
Last Update Date	:	07/02/2015

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