Basic Information
| Provider Information | |||||||||
| NPI: | 1649683590 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOSTRITSYNA | ||||||||
| FirstName: | MARIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 N LAFAYETTE ST | ||||||||
| Address2: | PROVIDENCE MEDICAL CENTER | ||||||||
| City: | SOUTH LYON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481782048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488493441 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 N LAFAYETTE ST | ||||||||
| Address2: | PROVIDENCE MEDICAL CENTER | ||||||||
| City: | SOUTH LYON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481782048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488493441 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2014 | ||||||||
| LastUpdateDate: | 06/09/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301105440 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.