Provider Demographics
NPI:1891983805
Name:MORENCI MEDICAL ASSOC PC
Entity Type:Organization
Organization Name:MORENCI MEDICAL ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIVAPRASAD
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-458-6848
Mailing Address - Street 1:240 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MORENCI
Mailing Address - State:MI
Mailing Address - Zip Code:49256-1455
Mailing Address - Country:US
Mailing Address - Phone:517-458-6848
Mailing Address - Fax:517-458-7614
Practice Address - Street 1:240 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MORENCI
Practice Address - State:MI
Practice Address - Zip Code:49256-1455
Practice Address - Country:US
Practice Address - Phone:517-458-6848
Practice Address - Fax:517-458-7614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI062948207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF98409Medicare UPIN