Provider Demographics
NPI:1568591063
Name:PETER A COSTANTINO JR DC PC
Entity Type:Organization
Organization Name:PETER A COSTANTINO JR DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:COSTANTINO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:586-443-5000
Mailing Address - Street 1:29856 SCHOENHERR RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-3600
Mailing Address - Country:US
Mailing Address - Phone:586-443-5000
Mailing Address - Fax:586-443-5002
Practice Address - Street 1:29856 SCHOENHERR RD
Practice Address - Street 2:SUITE 2
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-3600
Practice Address - Country:US
Practice Address - Phone:586-443-5000
Practice Address - Fax:586-443-5002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005635111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950E053280OtherBCBSM
MI950E053280OtherBCBSM