Michael C Liddell DO PLLC

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

5101011829 Issued in MI

Legal business name

MICHAEL C LIDDELL DO PLLC

Practice address

13105 Schavey Rd Ste 4
Dewitt, MI 48820-9014

Phone

(517) 668-0555

Fax

(517) 668-0554

NPI assigned

Mar 30, 2010

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Michael Charles Liddell, DONPI 1134239064

Title

Physician/Owner

Phone

(517) 668-0555

Specialties & licenses 1

Addresses

Other identifiers 4

Medicare fee-for-service enrollment

Enrolled in MI

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Michael Charles Liddell, D.O.

  • Family Medicine Physician
  • Dewitt, MI
  • NPI 1134239064
  Medicare reassignment NPD Authorized official
• Jennifer Kingsbury, PA-C

  • Medical Physician Assistant
  • Dewitt, MI
  • NPI 1255677738
  NPD (past)
• Damaris Deutsch, ARNP

  • Psychiatric/Mental Health Nurse Practitioner
  • Tulsa, OK
  • NPI 1699862573
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1269907200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1269907200000",
    "number": "1568787828",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "13105 SCHAVEY RD STE 4",
            "city": "DEWITT",
            "state": "MI",
            "postal_code": "488209014",
            "telephone_number": "517-668-0555",
            "fax_number": "517-668-0554"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "13105 SCHAVEY RD STE 4",
            "city": "DEWITT",
            "state": "MI",
            "postal_code": "488209014",
            "telephone_number": "517-668-0555",
            "fax_number": "517-668-0554"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MICHAEL C LIDDELL DO PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-03-30",
        "last_updated": "2010-03-30",
        "status": "A",
        "authorized_official_last_name": "LIDDELL",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "CHARLES",
        "authorized_official_title_or_position": "PHYSICIAN/OWNER",
        "authorized_official_telephone_number": "517-668-0555",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "MI",
            "license": "5101011829",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PHP",
            "identifier": "200000002295",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "5330080",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCN",
            "identifier": "P88692",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4303894",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Miranda Moncada-Sullivan, PT, DPT

• Family Medicine Physician in Dewitt, MI
• Providers in Dewitt, MI by specialty
• Family Medicine Physician in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 30, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.