Provider Demographics
NPI:1033168125
Name:MACHESKY, KELLY K (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:K
Last Name:MACHESKY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13350 24 MILE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-1826
Mailing Address - Country:US
Mailing Address - Phone:586-566-7100
Mailing Address - Fax:586-566-8088
Practice Address - Street 1:13350 24 MILE RD STE 200
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-1826
Practice Address - Country:US
Practice Address - Phone:586-566-7100
Practice Address - Fax:586-566-8088
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066553207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4455475Medicaid
MIG99217Medicare UPIN
MIN40170043Medicare ID - Type UnspecifiedMEDICARE