Provider Demographics
NPI:1821292723
Name:KOSSAK, MARIA N (DO)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:N
Last Name:KOSSAK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WAGNER CT
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2223
Mailing Address - Country:US
Mailing Address - Phone:313-562-4037
Mailing Address - Fax:
Practice Address - Street 1:22074 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2353
Practice Address - Country:US
Practice Address - Phone:313-565-9510
Practice Address - Fax:313-565-4410
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010416207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Not Answered207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4318019Medicaid
MI0N23730Medicare ID - Type Unspecified
MI4318019Medicaid