1962677104 NPI number — LUANA J KYSELKA MD PC

Table of content: (NPI 1962677104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962677104 NPI number — LUANA J KYSELKA MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUANA J KYSELKA MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962677104
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2877 CROOKS RD
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48084-4717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-643-6634
Provider Business Mailing Address Fax Number:
248-643-7165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2877 CROOKS ROAD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48084-4717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-643-6634
Provider Business Practice Location Address Fax Number:
248-643-7165
Provider Enumeration Date:
04/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KYSELKA
Authorized Official First Name:
LUANA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-643-6634

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  LK043787 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0630809 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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