Provider Demographics
NPI:1962677104
Name:LUANA J KYSELKA MD PC
Entity Type:Organization
Organization Name:LUANA J KYSELKA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUANA
Authorized Official - Middle Name:J
Authorized Official - Last Name:KYSELKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-643-6634
Mailing Address - Street 1:2877 CROOKS RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4717
Mailing Address - Country:US
Mailing Address - Phone:248-643-6634
Mailing Address - Fax:248-643-7165
Practice Address - Street 1:2877 CROOKS ROAD
Practice Address - Street 2:SUITE D
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4717
Practice Address - Country:US
Practice Address - Phone:248-643-6634
Practice Address - Fax:248-643-7165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILK043787207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0630809OtherBCBSM
MIB42897Medicare UPIN
MIMI3186Medicare PIN