Provider Demographics
NPI:1932438637
Name:CHARLES R. KOSSMAN, M.D., INC.
Entity Type:Organization
Organization Name:CHARLES R. KOSSMAN, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:KOSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-287-9910
Mailing Address - Street 1:5555 RESERVOIR DR
Mailing Address - Street 2:#306
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5134
Mailing Address - Country:US
Mailing Address - Phone:619-287-9910
Mailing Address - Fax:619-287-3526
Practice Address - Street 1:5555 RESERVOIR DR
Practice Address - Street 2:#306
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5134
Practice Address - Country:US
Practice Address - Phone:619-287-9910
Practice Address - Fax:619-287-3526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-09
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28857207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1184799892OtherMEDICARE INDIVIDUAL NPI
CACN534ZOtherMEDICARE INDIVIDUAL PTAN
CACN538AOtherMEDICARE GROUP PTAN
CA1184799892OtherMEDICARE INDIVIDUAL NPI
CAA43885Medicare UPIN