Provider Demographics
NPI:1528018678
Name:SISKOSKY, MATTHEW J (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:SISKOSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:30575 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-0980
Mailing Address - Country:US
Mailing Address - Phone:248-280-8550
Mailing Address - Fax:248-280-8567
Practice Address - Street 1:30575 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073
Practice Address - Country:US
Practice Address - Phone:248-280-8550
Practice Address - Fax:248-280-8567
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301075890207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N57760009Medicare PIN