Provider Demographics
NPI:1427214857
Name:KOLANKO, NICHOLAS MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:MICHAEL
Last Name:KOLANKO
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 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DR
Practice Address - Street 2:2ND FLOOR TAUBMAN CENTER RECP A
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5326
Practice Address - Country:US
Practice Address - Phone:734-936-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50104-202085R0202X
MI43010985892085R0202X
IL1250523222085R0202X
WI67438-202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125052322OtherILLINOIS LICENSE NUMBER, TEMPORARY PHYSICIAN LICENSE
WI1427214857Medicaid