Provider Demographics
NPI:1497028989
Name:SUSAN KOSLOW M.D.,INC
Entity Type:Organization
Organization Name:SUSAN KOSLOW M.D.,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DOAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-234-4243
Mailing Address - Street 1:PO BOX 10037
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47801-0037
Mailing Address - Country:US
Mailing Address - Phone:812-234-4243
Mailing Address - Fax:812-478-3663
Practice Address - Street 1:477 E TRAILWOOD DR
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-9606
Practice Address - Country:US
Practice Address - Phone:812-234-4243
Practice Address - Fax:812-478-3663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042883A261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100462130AMedicaid
INM100067995OtherMEDICARE PTAN
INM100067995OtherMEDICARE PTAN