Healthcare Provider Details

I. General information

NPI: 1770271710
Provider Name (Legal Business Name): KONSTANTINOS GRILLAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 08/15/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TRINITY HEALTH ACADEMIC FAMILY MEDICINE-NORTHWEST LIVON 37595 SEVEN MILE RD., SUITE 210
LIVONIA MI
48152
US

IV. Provider business mailing address

TRINITY HEALTH LAVONIA HOSPITAL 36475 FIVE MILE RD
LIVONIA MI
48154
US

V. Phone/Fax

Practice location:
  • Phone: 734-853-5690
  • Fax: 734-430-9388
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: