Healthcare Provider Details

I. General information

NPI: 1508329699
Provider Name (Legal Business Name): KEVIN BRUCE MARCHILDON CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2019
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5325 ELLIOTT DR FL 2
YPSILANTI MI
48197-8633
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DR STE J2000
ANN ARBOR MI
48105-9484
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-8000
  • Fax: 734-712-8010
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704246454
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: