MEDICARE: RONALD KOSTKA CSW

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	1041C0700X	Clinical Social Worker	6801064631	MI

General Provider Information

NPI Number	:	1992761340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONALD KOSTKA CSW

Provider Business Mailing Address
First Line	:	812 E JOLLY RD
Second Line	:	STE 210
City	:	LANSING
State	:	MI
Zip	:	48910-6818
Country	:	US
Telephone Number	:	517-346-8410
Fax Number	:	517-346-8291

Provider Business Practice Location Address
First Line	:	551 COURTHOUSE DR
Second Line	:	STE 5
City	:	CHARLOTTE
State	:	MI
Zip	:	48813-1054
Country	:	US
Telephone Number	:	517-543-5100
Fax Number	:	517-346-8291

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

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	07/08/2007

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