Healthcare Provider Details

I. General information

NPI: 1619968872
Provider Name (Legal Business Name): LUANA J KYSELKA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2877 CROOKS RD STE D
TROY MI
48084-4717
US

IV. Provider business mailing address

2877 CROOKS RD STE D
TROY MI
48084-4717
US

V. Phone/Fax

Practice location:
  • Phone: 248-643-6634
  • Fax: 248-643-7165
Mailing address:
  • Phone: 248-643-6634
  • Fax: 248-643-7165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number4301043787
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301043787
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number4301043787
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: