Healthcare Provider Details

I. General information

NPI: 1174139612
Provider Name (Legal Business Name): KOSTIANTYN ROMANIV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30000 NORTHWESTERN HWY
FARMINGTON HILLS MI
48334-3227
US

IV. Provider business mailing address

30000 NORTHWESTERN HWY
FARMINGTON HILLS MI
48334-3227
US

V. Phone/Fax

Practice location:
  • Phone: 248-974-2511
  • Fax:
Mailing address:
  • Phone: 248-974-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4351046269
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: