Provider Demographics
NPI:1457543555
Name:EDWARD P. KOSANKE, OPTOMETRIST P.C
Entity type:Organization
Organization Name:EDWARD P. KOSANKE, OPTOMETRIST P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:KOSANKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:231-627-5666
Mailing Address - Street 1:730 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-2220
Mailing Address - Country:US
Mailing Address - Phone:231-627-5666
Mailing Address - Fax:
Practice Address - Street 1:730 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-2220
Practice Address - Country:US
Practice Address - Phone:231-627-5666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002498152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI945103234Medicaid
MI0427340001Medicare NSC
MI0A66502Medicare PIN
MI945103234Medicaid