Provider Demographics
NPI:1811976053
Name:KLYACHKIN, MICHAEL L (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:KLYACHKIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:688 WALNUT ST
Mailing Address - Street 2:STE 200
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2677
Mailing Address - Country:US
Mailing Address - Phone:478-742-7566
Mailing Address - Fax:478-743-2804
Practice Address - Street 1:688 WALNUT ST
Practice Address - Street 2:STE 200
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2677
Practice Address - Country:US
Practice Address - Phone:478-742-7566
Practice Address - Fax:478-743-2804
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2008-08-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA547602086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
511I770014OtherMEDICARE
GA519931565AMedicaid
GA519931565AMedicaid
511I770014OtherMEDICARE