Provider Demographics
NPI:1841299468
Name:KOSCIELNIAK, JOSEPH B JR (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:B
Last Name:KOSCIELNIAK
Suffix:JR
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 1:5587 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-2632
Mailing Address - Country:US
Mailing Address - Phone:219-887-9506
Mailing Address - Fax:219-884-3761
Practice Address - Street 1:5587 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-2632
Practice Address - Country:US
Practice Address - Phone:219-887-9506
Practice Address - Fax:219-884-3761
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028974174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000081974OtherANTHEM
IN100353230AMedicaid
IN000000081974OtherANTHEM
IN472970BMedicare PIN
C87726Medicare PIN