Provider Demographics
NPI:1316706674
Name:MAIKOSKI, PHOENIX KHALID
Entity type:Individual
Prefix:
First Name:PHOENIX
Middle Name:KHALID
Last Name:MAIKOSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4288 ESCAPE DR APT 102C
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-6761
Mailing Address - Country:US
Mailing Address - Phone:269-615-0494
Mailing Address - Fax:
Practice Address - Street 1:1500 LAMONT AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-4156
Practice Address - Country:US
Practice Address - Phone:269-385-6128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker