Provider Demographics
NPI:1437129442
Name:COSGROVE, MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:COSGROVE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45209 OAK FOREST DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-4440
Mailing Address - Country:US
Mailing Address - Phone:734-241-3891
Mailing Address - Fax:734-214-0014
Practice Address - Street 1:45209 OAK FOREST DR
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48168-4440
Practice Address - Country:US
Practice Address - Phone:734-241-3891
Practice Address - Fax:734-214-0014
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704153806367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered