Provider Demographics
NPI:1154622595
Name:MT MORRIS FAMILY MEDICINE LLC
Entity type:Organization
Organization Name:MT MORRIS FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MELODIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KNICELY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-686-1997
Mailing Address - Street 1:8434 N SAGINAW RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:MI
Mailing Address - Zip Code:48458-1190
Mailing Address - Country:US
Mailing Address - Phone:810-686-1997
Mailing Address - Fax:810-686-1820
Practice Address - Street 1:8434 N SAGINAW RD
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:MI
Practice Address - Zip Code:48458-1190
Practice Address - Country:US
Practice Address - Phone:810-686-1997
Practice Address - Fax:810-686-1820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMK051305207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0802500611OtherBCBS PIN
MI448882310Medicaid
MI0802500611OtherBCBS PIN