MEDICARE: DR. KRISTIN L. KOSANKE M.D.

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	208000000X	Pediatrics Physician	L0351	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	1710006598	OTHER	KELLER GROUP NPI
2	8K6663	OTHER	BCBS
3	0046KV	OTHER	BCBS-GROUP
4	1164541967	OTHER	FORT WORTH GROUP NPI

General Provider Information

NPI Number	:	1588628713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRISTIN L. KOSANKE M.D.

Provider Business Mailing Address
First Line	:	230 N RUFE SNOW DR
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-4226
Country	:	US
Telephone Number	:	817-337-5503
Fax Number	:	817-337-0110

Provider Business Practice Location Address
First Line	:	230 N RUFE SNOW DR
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-4226
Country	:	US
Telephone Number	:	817-337-5503
Fax Number	:	817-337-0110

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

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	03/30/2009

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