Healthcare Provider Details

I. General information

NPI: 1508997032
Provider Name (Legal Business Name): MICHAEL BARRY GELLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

36800 WOODWARD AVE STE 109
BLOOMFIELD HILLS MI
48304-0916
US

V. Phone/Fax

Practice location:
  • Phone: 313-874-4806
  • Fax: 313-876-1305
Mailing address:
  • Phone: 248-642-4846
  • Fax: 248-642-5313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number2735A
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number30028
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301030689
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD430264
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: