Healthcare Provider Details

I. General information

NPI: 1629204797
Provider Name (Legal Business Name): CASSIE TOMINNA KONJA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 E 12 MILE RD
WARREN MI
48093-3570
US

IV. Provider business mailing address

4967 CROOKS RD STE 130
TROY MI
48098-5801
US

V. Phone/Fax

Practice location:
  • Phone: 586-576-4140
  • Fax: 586-576-4146
Mailing address:
  • Phone: 248-952-1601
  • Fax: 248-952-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101018206
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: