Healthcare Provider Details

I. General information

NPI: 1730346180
Provider Name (Legal Business Name): NATHAN MICHAEL NOVOTNY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 03/29/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 W 13 MILE RD STE 307
ROYAL OAK MI
48073-6770
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 248-551-2400
  • Fax: 248-551-6556
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number4301104010
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: