Basic Information
| Provider Information | |||||||||
| NPI: | 1780779330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOSIM | ||||||||
| FirstName: | SUDJONO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIM | ||||||||
| OtherFirstName: | HONG T JAY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 718 N. MACOMB | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342408400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 718 N. MACOMB | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342408400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2085R0202X | 4301040246 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 12915 | 01 | MI | COMMUNITY CHOICE OF MI | OTHER | 3442516 | 01 | MI | HEALTH PLAN OF MI | OTHER | 3442490 | 05 | MI | MEDICAID | 3442516 | 01 | MI | MOLINA HEALTHCARE | OTHER | 802982 | 01 | MI | COMMUNITY CARE PLAN | OTHER | 38338429803 | 01 | MI | CNA HEALTH SERVICES | OTHER |