Provider Demographics
NPI:1316941255
Name:COSGROVE, EMMETT DEWAYNE (OD)
Entity type:Individual
Prefix:
First Name:EMMETT
Middle Name:DEWAYNE
Last Name:COSGROVE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11282 M140 HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-9405
Mailing Address - Country:US
Mailing Address - Phone:269-637-1569
Mailing Address - Fax:269-637-4519
Practice Address - Street 1:11282 M140 HIGHWAY
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-9405
Practice Address - Country:US
Practice Address - Phone:269-637-1569
Practice Address - Fax:269-637-4519
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI002521152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
22-32002OtherUNITED HEALTH CARE/PHP
900H06501OtherBLUE CROSS/BLUE SHIELD
MI5098573Medicaid
22-32002OtherUNITED HEALTH CARE/PHP
MI5098573Medicaid
MI0H06501Medicare PIN