MEDICARE: DR. MIKE KOZMINSKI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	R4J56	MO
2	208800000X	Urology Physician	4301049435	MI

General Provider Information

NPI Number	:	1093816316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MIKE KOZMINSKI M.D.

Provider Business Mailing Address
First Line	:	5603 STONEBRIDGE DR SE
Second Line	:
City	:	GRANDVILLE
State	:	MI
Zip	:	49418
Country	:	US
Telephone Number	:	816-248-2373
Fax Number	:

Provider Business Practice Location Address
First Line	:	611 E MAIN ST
Second Line	:
City	:	HART
State	:	MI
Zip	:	49420-1190
Country	:	US
Telephone Number	:	231-873-6900
Fax Number	:	231-873-1825

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	03/15/2023

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