Provider Demographics
NPI:1386803757
Name:DR. JOSEPH S KOSTRZEWSKI SC
Entity type:Organization
Organization Name:DR. JOSEPH S KOSTRZEWSKI SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:KOSTRZEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:414-617-1717
Mailing Address - Street 1:1717 W GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-2658
Mailing Address - Country:US
Mailing Address - Phone:414-671-1717
Mailing Address - Fax:414-671-5190
Practice Address - Street 1:1717 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-2658
Practice Address - Country:US
Practice Address - Phone:414-671-1717
Practice Address - Fax:414-671-5190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17121261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000080002Medicare PIN