Healthcare Provider Details

I. General information

NPI: 1336702216
Provider Name (Legal Business Name): CHRISTOPHER J MCMELLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23550 PARK ST STE 100
DEARBORN MI
48124-2592
US

IV. Provider business mailing address

23550 PARK ST STE 100
DEARBORN MI
48124-2592
US

V. Phone/Fax

Practice location:
  • Phone: 313-730-0500
  • Fax: 313-730-0606
Mailing address:
  • Phone: 313-730-0500
  • Fax: 313-730-0606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4301514122
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number4301514122
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: