Basic Information
Provider Information | |||||||||
NPI: | 1467436923 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KONSTAN | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 24701 EUCLID AVE | ||||||||
Address2: | THIRD FLOOR BILLING SERVICES | ||||||||
City: | EUCLID | ||||||||
State: | OH | ||||||||
PostalCode: | 441171714 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2165935500 | ||||||||
FaxNumber: | 2168445922 | ||||||||
Practice Location | |||||||||
Address1: | 29000 CENTER RIDGE RD | ||||||||
Address2: |   | ||||||||
City: | WESTLAKE | ||||||||
State: | OH | ||||||||
PostalCode: | 441455293 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2165935500 | ||||||||
FaxNumber: | 2168445922 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2005 | ||||||||
LastUpdateDate: | 12/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35061019K | OH | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 300114400 | 01 |   | RAILROAD | OTHER | 0880524 | 05 | OH |   | MEDICAID |