Healthcare Provider Details

I. General information

NPI: 1750678264
Provider Name (Legal Business Name): MICHAEL KOZMINSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 CHERRY ST SE STE 202
GRAND RAPIDS MI
49503-4607
US

IV. Provider business mailing address

245 CHERRY ST SE STE 202
GRAND RAPIDS MI
49503-4607
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-3551
  • Fax: 616-459-1060
Mailing address:
  • Phone: 616-459-3551
  • Fax: 616-459-1060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4301098131
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: