Provider Demographics
NPI:1932349594
Name:KOSCIUSKO MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:KOSCIUSKO MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR DIRECTOR PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:6920 POINTE INVERNESS WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3513
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:2235 DUBOIS DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3212
Practice Address - Country:US
Practice Address - Phone:574-267-8189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN262490Medicare PIN