Basic Information
| Provider Information | |||||||||
| NPI: | 1528317153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POLETIS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 FORD PL STE 2E | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482023450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138744806 | ||||||||
| FaxNumber: | 3138761305 | ||||||||
| Practice Location | |||||||||
| Address1: | 15855 19 MILE RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862632113 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2012 | ||||||||
| LastUpdateDate: | 09/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 085004402 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 5601007695 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.