Healthcare Provider Details

I. General information

NPI: 1841299468
Provider Name (Legal Business Name): JOSEPH B KOSCIELNIAK JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5587 BROADWAY
MERRILLVILLE IN
46410-2632
US

IV. Provider business mailing address

5587 BROADWAY
MERRILLVILLE IN
46410-2632
US

V. Phone/Fax

Practice location:
  • Phone: 219-887-9506
  • Fax: 219-884-3761
Mailing address:
  • Phone: 219-887-9506
  • Fax: 219-884-3761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number01028974
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: