Provider Demographics
NPI:1720007933
Name:KOSLOW, SUSAN AUDREY (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:AUDREY
Last Name:KOSLOW
Suffix:
Gender:F
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 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
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042883A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100462130AMedicaid
E99495Medicare UPIN
INM100067995Medicare PIN