Provider Demographics
NPI:1417955469
Name:KOSMAN, MICHAEL WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:KOSMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 CHERRY DR
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1112
Mailing Address - Country:US
Mailing Address - Phone:309-944-5301
Mailing Address - Fax:309-944-2010
Practice Address - Street 1:910 CHERRY DR
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1112
Practice Address - Country:US
Practice Address - Phone:309-944-5301
Practice Address - Fax:309-944-2010
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038 003811111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT37209Medicare UPIN