Provider Demographics
NPI:1720068612
Name:COSGROVE, THOMAS M
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:COSGROVE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 ALBIA RD
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-3946
Mailing Address - Country:US
Mailing Address - Phone:641-684-2261
Mailing Address - Fax:641-684-2254
Practice Address - Street 1:1429 ALBIA RD
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-3946
Practice Address - Country:US
Practice Address - Phone:641-684-2261
Practice Address - Fax:641-684-2254
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06319111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0289600Medicaid
53793OtherBCBS
480870Medicare UPIN
53793OtherBCBS