Provider Demographics
NPI:1568787828
Name:MICHAEL C LIDDELL DO PLLC
Entity Type:Organization
Organization Name:MICHAEL C LIDDELL DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:LIDDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:517-668-0555
Mailing Address - Street 1:13105 SCHAVEY RD STE 4
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-9014
Mailing Address - Country:US
Mailing Address - Phone:517-668-0555
Mailing Address - Fax:517-668-0554
Practice Address - Street 1:13105 SCHAVEY RD STE 4
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:MI
Practice Address - Zip Code:48820-9014
Practice Address - Country:US
Practice Address - Phone:517-668-0555
Practice Address - Fax:517-668-0554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011829207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI200000002295OtherPHP
MI5330080OtherBCBS
MIP88692OtherBCN
MI4303894Medicaid
MI200000002295OtherPHP
MI5330080OtherBCBS