Provider Demographics
NPI:1821044637
Name:KOSEL, ZDZISLAW JERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:ZDZISLAW
Middle Name:JERRY
Last Name:KOSEL
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 1:416 E MONROE ST
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-2371
Mailing Address - Country:US
Mailing Address - Phone:574-232-8119
Mailing Address - Fax:574-288-0235
Practice Address - Street 1:416 E MONROE ST
Practice Address - Street 2:STE 200
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-2371
Practice Address - Country:US
Practice Address - Phone:574-232-8119
Practice Address - Fax:574-288-0235
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056113A174400000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200381040Medicaid
INH44829Medicare UPIN