MEDICARE: FOUR CORNERS MEDICAL CENTER, LLC

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1295678605
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUR CORNERS MEDICAL CENTER, LLC

Provider Business Mailing Address
First Line	:	10603 EMERALD CHASE DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32836-5855
Country	:	US
Telephone Number	:	407-844-7323
Fax Number	:	863-424-8823

Provider Business Practice Location Address
First Line	:	106 POLO PARK EAST BLVD
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33897-9407
Country	:	US
Telephone Number	:	863-424-8900
Fax Number	:	863-424-8823

Authorized Official
Title or Position	:	PRESIDENT-OWNER
Name	:	DR. SRINATH R KOSANAM
Credential	:	MD
Telephone Number	:	407-844-7323

Provider Enumeration Date	:	04/10/2026
Last Update Date	:	04/10/2026

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