Provider Demographics
NPI:1508997032
Name:GELLIS, MICHAEL BARRY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BARRY
Last Name:GELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36800 WOODWARD AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-0915
Mailing Address - Country:US
Mailing Address - Phone:248-642-4846
Mailing Address - Fax:248-642-5313
Practice Address - Street 1:36800 WOODWARD AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-0915
Practice Address - Country:US
Practice Address - Phone:248-642-4846
Practice Address - Fax:248-642-5313
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301030689208200000X
WY2735A208200000X
PAMD430264208200000X
NC30028208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101090399Medicaid
MI0638436Medicare ID - Type Unspecified
MIB44607Medicare UPIN
WY307612Medicare ID - Type Unspecified