Provider Demographics
NPI:1265472393
Name:KOSHNICK, ROBERT A (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:KOSHNICK
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 1:1027 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3409
Mailing Address - Country:US
Mailing Address - Phone:218-847-5611
Mailing Address - Fax:218-847-0881
Practice Address - Street 1:1027 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3409
Practice Address - Country:US
Practice Address - Phone:218-847-5611
Practice Address - Fax:218-847-0881
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19195207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN17262Medicaid
MN6406OtherNDBS #
MNDA9031015665OtherPREFERRED ONE #
ND1031OtherNDBS #
MN107946OtherUCARE #
MN636375000Medicaid
MNMN100024OtherLHS/BANNERHEALTH #
MN9044868OtherAMERICA'S PPO/ARAZ #
MNHP19530OtherHEALTHPARTNERS #
MN0122666OtherMEDICA #
MN106057OtherMEDICA #
MN50321KOOtherMNBS #
MN61236KOOtherMNBS #
MN089004404Medicare ID - Type UnspecifiedMN MEDICARE #
MN17262Medicaid
MNMN100024OtherLHS/BANNERHEALTH #
MN9044868OtherAMERICA'S PPO/ARAZ #