=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932438637
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES R. KOSSMAN, M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2009
-----------------------------------------------------
Last Update Date | 12/22/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5555 RESERVOIR DR #306
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92120-5134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-287-9910
-----------------------------------------------------
Fax | 619-287-3526
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5555 RESERVOIR DR #306
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92120-5134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-287-9910
-----------------------------------------------------
Fax | 619-287-3526
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHARLES RICHARD KOSSMAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 619-287-9910
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | G28857
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------