Healthcare Provider Details

I. General information

NPI: 1932640398
Provider Name (Legal Business Name): MARYBETH KOSTIUK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2017
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58024 VAN DYKE RD
WASHINGTON MI
48094-4518
US

IV. Provider business mailing address

58024 VAN DYKE RD
WASHINGTON MI
48094-4518
US

V. Phone/Fax

Practice location:
  • Phone: 586-781-5535
  • Fax: 586-781-6063
Mailing address:
  • Phone: 586-781-5535
  • Fax: 586-781-6063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101023202
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: