Basic Information
| Provider Information | |||||||||
| NPI: | 1710926399 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSTANTINO | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BLVD STE 3D | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480333849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221863 | ||||||||
| FaxNumber: | 9475220307 | ||||||||
| Practice Location | |||||||||
| Address1: | 14319 DIX TOLEDO RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342850677 | ||||||||
| FaxNumber: | 7342853574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101006373 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 791126254 | 01 | MEDICARE RAILROAD | OTHER | C3241 | 01 | M-CARE | OTHER | E26804 | 01 | HEALTH ALLIANCE PLAN | OTHER | 125036 | 01 | CARE CHOICES | OTHER | 111059129 | 05 | MI | MEDICAID | 5823153 | 01 | MI | BLUE CROSS | OTHER |