Basic Information
| Provider Information | |||||||||
| NPI: | 1194955104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSTELLIC | ||||||||
| FirstName: | CORINNE | ||||||||
| MiddleName: | DIANNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BLVD SUITE 3D | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480333849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221860 | ||||||||
| FaxNumber: | 9475220307 | ||||||||
| Practice Location | |||||||||
| Address1: | 44199 DEQUINDRE RD STE 612 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480851128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489645170 | ||||||||
| FaxNumber: | 2489645175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2009 | ||||||||
| LastUpdateDate: | 07/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | H0079964 | MD | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208600000X | 5101018177 | MI | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.