Provider Demographics
NPI:1093816316
Name:KOZMINSKI, MIKE (MD)
Entity Type:Individual
Prefix:DR
First Name:MIKE
Middle Name:
Last Name:KOZMINSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5603 STONEBRIDGE DR SE
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418
Mailing Address - Country:US
Mailing Address - Phone:816-248-2373
Mailing Address - Fax:
Practice Address - Street 1:611 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HART
Practice Address - State:MI
Practice Address - Zip Code:49420-1190
Practice Address - Country:US
Practice Address - Phone:231-873-6900
Practice Address - Fax:231-873-1825
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4J56174400000X
MI4301049435208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202678918Medicaid
MO340006076OtherRAILROAD MEDICARE
MO15236026OtherBLUE CROSS BLUE SHIELD KC
MO202678918Medicaid
MOE03987Medicare UPIN