MEDICARE: EILEEN KOSZTOWNY

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	363LF0000X	Family Nurse Practitioner	4704279336	MI

General Provider Information

NPI Number	:	1881061299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EILEEN KOSZTOWNY

Provider Business Mailing Address
First Line	:	4104 BOLD MDWS
Second Line	:
City	:	OAKLAND TWP
State	:	MI
Zip	:	48306-1489
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2961 WALMSLEY CIRCLE DR
Second Line	:
City	:	LAKE ORION
State	:	MI
Zip	:	48360-1647
Country	:	US
Telephone Number	:	248-941-4217
Fax Number	:

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

Provider Enumeration Date	:	09/01/2015
Last Update Date	:	10/25/2021

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