Provider Demographics
NPI:1134239064
Name:LIDDELL, MICHAEL CHARLES (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:LIDDELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011829207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0170374OtherPHP FAMILY CARE
MI4303894Medicaid
MI5330080OtherBCBS
MI4303894Medicaid
MI0170374OtherPHP FAMILY CARE