MEDICARE: EMMETT DEWAYNE COSGROVE OD

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	152W00000X	Optometrist	002521	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	22-32002	OTHER	UNITED HEALTH CARE/PHP
2	900H06501	OTHER	BLUE CROSS/BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316941255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMETT DEWAYNE COSGROVE OD

Provider Business Mailing Address
First Line	:	11282 M140 HIGHWAY
Second Line	:
City	:	SOUTH HAVEN
State	:	MI
Zip	:	49090-9405
Country	:	US
Telephone Number	:	269-637-1569
Fax Number	:	269-637-4519

Provider Business Practice Location Address
First Line	:	11282 M140 HIGHWAY
Second Line	:
City	:	SOUTH HAVEN
State	:	MI
Zip	:	49090-9405
Country	:	US
Telephone Number	:	269-637-1569
Fax Number	:	269-637-4519

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	08/18/2008

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