Provider Demographics
NPI:1134640477
Name:KOSKI STARK GHODGE LLC
Entity Type:Organization
Organization Name:KOSKI STARK GHODGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PARESH
Authorized Official - Middle Name:S
Authorized Official - Last Name:GHODGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-413-7893
Mailing Address - Street 1:8014 HIGHWAY 55 # 515
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4712
Mailing Address - Country:US
Mailing Address - Phone:763-200-1185
Mailing Address - Fax:763-374-3201
Practice Address - Street 1:8014 HIGHWAY 55 # 515
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4712
Practice Address - Country:US
Practice Address - Phone:763-200-1185
Practice Address - Fax:763-374-3201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-27
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN229221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty