Healthcare Provider Details

I. General information

NPI: 1033154190
Provider Name (Legal Business Name): KOSIT PRIEB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W LINCOLN ST SUITE 200
BELLEVILLE IL
62220-1902
US

IV. Provider business mailing address

379 OAK HILL DR
BELLEVILLE IL
62223-2231
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-2500
  • Fax: 618-233-2520
Mailing address:
  • Phone: 618-398-0231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036-047055
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: