Provider Demographics
NPI:1871560979
Name:NOLAN, KEVIN DAVID (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:DAVID
Last Name:NOLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22250 PROVIDENCE DR
Mailing Address - Street 2:SUITE 555
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4825
Mailing Address - Country:US
Mailing Address - Phone:248-424-5748
Mailing Address - Fax:248-443-1706
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:SUITE 555
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:248-424-5748
Practice Address - Fax:248-443-1706
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKN0622522086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P33080OtherPTAN
MI3488275Medicaid
MIF67824Medicare UPIN