Provider Demographics
NPI:1548205222
Name:KOS, ANTONI J (MD)
Entity Type:Individual
Prefix:
First Name:ANTONI
Middle Name:J
Last Name:KOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-997-3461
Mailing Address - Fax:618-993-6042
Practice Address - Street 1:3307 LOGAN DR STE B
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3732
Practice Address - Country:US
Practice Address - Phone:618-997-3461
Practice Address - Fax:618-993-6042
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109286208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109286Medicaid
IL7210895OtherAETNA
IL3932056OtherBCBS OF IL
IL779555OtherHEALTHLINK
IL130745OtherHEALTH ALLIANCE
IL214881Medicare PIN
IL7210895OtherAETNA
ILK37802Medicare PIN