Basic Information
Provider Information | |||||||||
NPI: | 1164459368 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOSSAK | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 87 MCGREGOR ST | ||||||||
Address2: | DARTMOUTH HITCHCOCK - CHILD NEUROLOGY | ||||||||
City: | MANCHESTER | ||||||||
State: | NH | ||||||||
PostalCode: | 031023765 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036952500 | ||||||||
FaxNumber: | 6036952960 | ||||||||
Practice Location | |||||||||
Address1: | 87 MCGREGOR ST | ||||||||
Address2: | DARTMOUTH HITCHCOCK - CHILD NEUROLOGY | ||||||||
City: | MANCHESTER | ||||||||
State: | NH | ||||||||
PostalCode: | 031023765 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036952500 | ||||||||
FaxNumber: | 6036952960 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/26/2006 | ||||||||
LastUpdateDate: | 06/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0008X | 8711 | NH | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities | 2084N0402X | 8711 | NH | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0402X | 213688 | MA | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084S0012X | 8711 | NH | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine |
No ID Information.