Provider Demographics
NPI:1437286655
Name:KOKOMO SURGICAL GROUP, LLC
Entity Type:Organization
Organization Name:KOKOMO SURGICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNEMARIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:DESANTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-456-1790
Mailing Address - Street 1:2000 W BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-6079
Mailing Address - Country:US
Mailing Address - Phone:765-456-1790
Mailing Address - Fax:765-457-3561
Practice Address - Street 1:2000 W BOULEVARD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6079
Practice Address - Country:US
Practice Address - Phone:765-456-1790
Practice Address - Fax:765-457-3561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100420490Medicaid
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