MEDICARE: NICOLE POLIDORI KOSKI 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	4901003891	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	410046052	OTHER	MI	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	0166710001	OTHER	MI	ADMINASTAR FEDERAL

General Provider Information

NPI Number	:	1417987603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE POLIDORI KOSKI OD

Provider Business Mailing Address
First Line	:	13400 E 15 MILE RD
Second Line	:
City	:	STERLING HTS
State	:	MI
Zip	:	48312
Country	:	US
Telephone Number	:	586-939-1122
Fax Number	:	586-939-9328

Provider Business Practice Location Address
First Line	:	13400 E 15 MILE RD
Second Line	:
City	:	STERLING HTS
State	:	MI
Zip	:	48312
Country	:	US
Telephone Number	:	586-939-1122
Fax Number	:	586-939-9328

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

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	02/21/2013

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Directions to “ NICOLE POLIDORI KOSKI OD” Practice Location

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