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NPI Code Detail

MEDICARE: DR. DENNIS D COSTERISAN D.O.

MEDICARE: DR. DENNIS D COSTERISAN D.O.
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
1207Q00000XFamily Medicine Physician036071025IL

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1080105720OTHERILRAILROAD MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2178026OTHERILHEALTHLINK
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
40007005197OTHERILBLUE CROSS BLUE SHIELD

General Provider Information

NPI Number : 1578565701
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. DENNIS D COSTERISAN D.O.
Provider Business Mailing Address
First Line : 320 E CENTRAL AVE
Second Line :
City : DECATUR
State : IL
Zip : 62521-4665
Country : US
Telephone Number : 217-877-9117
Fax Number : 217-728-2580
Provider Business Practice Location Address
First Line : 320 E CENTRAL AVE
Second Line :
City : DECATUR
State : IL
Zip : 62521-4665
Country : US
Telephone Number : 217-877-9117
Fax Number : 217-877-3078
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/01/2005
Last Update Date : 01/25/2022

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