Basic Information
| Provider Information | |||||||||
| NPI: | 1275517401 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOSANOVICH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 S MICHIGAN AVE | ||||||||
| Address2: | B-390 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606162333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125676691 | ||||||||
| FaxNumber: | 3123287895 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 S MICHIGAN AVE | ||||||||
| Address2: | B-390 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606162333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125676691 | ||||||||
| FaxNumber: | 3123287895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 06/12/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 036100871 | IL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 01621679 | 01 | IL | BCBS OF IL | OTHER | 036100871 | 05 | IL | MEDICAID |