Provider Demographics
NPI:1265611149
Name:KRIS A. KOSTRZEWSKI M.D./PHD FAMILY PRACTICE LLC.
Entity type:Organization
Organization Name:KRIS A. KOSTRZEWSKI M.D./PHD FAMILY PRACTICE LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:CHMIELOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:419-843-8888
Mailing Address - Street 1:6545 W CENTRAL AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-1034
Mailing Address - Country:US
Mailing Address - Phone:419-843-8888
Mailing Address - Fax:
Practice Address - Street 1:6545 W CENTRAL AVE STE 208
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1034
Practice Address - Country:US
Practice Address - Phone:419-843-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071412174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2031018Medicaid
OHG42672Medicare UPIN
OH2031018Medicaid