Healthcare Provider Details

I. General information

NPI: 1528644499
Provider Name (Legal Business Name): BRADLEY THOMAS NOWOSIELSKI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 WILSON RD STE A233
EAST LANSING MI
48824-6410
US

IV. Provider business mailing address

PO BOX 935983
ATLANTA GA
31193-5983
US

V. Phone/Fax

Practice location:
  • Phone: 517-355-8416
  • Fax:
Mailing address:
  • Phone: 844-266-8268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2025-03877
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: