Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 5101018177 | MI |
Y | 208600000X | Surgeon | 5101018177 | MI |
N | 2086X0206X | Surgical Oncologist | H0079964 | MD |
NPI | 1194955104 |
---|---|
Provider Name | Dr. Corinne Dianne Costellic |
First Address | Southfield, MI 48033-3849 |
Second Address | Troy, MI 48085-1128 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/07/2009 |
Last Update Date | 13/02/2019 |