Healthcare Provider Details

I. General information

NPI: 1477420479
Provider Name (Legal Business Name): KEVIN NOLAN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2025
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22250 PROVIDENCE DR STE 608
SOUTHFIELD MI
48075-6214
US

IV. Provider business mailing address

7650 COOLEY LAKE RD PO BOX 43
UNION LAKE MI
48387-9998
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-6350
  • Fax: --
Mailing address:
  • Phone: 248-231-8381
  • Fax: --

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KEVIN NOLAN
Title or Position: OWNER
Credential: MD
Phone: 248-231-8381