Basic Information
| Provider Information | |||||||||
| NPI: | 1164620746 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TSAGARATOS | ||||||||
| FirstName: | COSTANDINOS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38935 ANN ARBOR ROAD | ||||||||
| Address2: | PEC CREDENTIALING HFM | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481503397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482373226 | ||||||||
| FaxNumber: | 8662506385 | ||||||||
| Practice Location | |||||||||
| Address1: | 15855 19 MILE RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480383504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862632601 | ||||||||
| FaxNumber: | 5862632589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2007 | ||||||||
| LastUpdateDate: | 10/26/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 5101020835 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 12655418 | 01 | MI | CAQH | OTHER |