# KOSCIUSKO MEDICAL GROUP LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1932349594
- **Authorized official:** KRISTINA MUSIC (SR DIRECTOR PROVIDER ENROLLMENT)
- **Authorized official phone:** (615) 465-7377

## Contact information

- **Practice address:** 2235 DUBOIS DR, WARSAW, IN 46580-3212
- **Practice address phone:** (574) 267-8189
- **Mailing address:** 6920 POINTE INVERNESS WAY, SUITE 200, FORT WAYNE, IN 46804-7934
- **Mailing address phone:** (260) 479-3513
- **Mailing address fax:** (260) 479-3520

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 174400000X | Specialist | — | NULL | — |
| 174400000X | Specialist | — | — | — |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 207R00000X | Internal Medicine Physician | — | NULL | — |
| 207R00000X | Internal Medicine Physician | — | — | — |
| 207RH0003X | Hematology & Oncology Physician | — | NULL | — |
| 207RH0003X | Hematology & Oncology Physician | — | — | — |
| 207X00000X | Orthopaedic Surgery Physician | — | NULL | — |
| 207X00000X | Orthopaedic Surgery Physician | — | — | — |
| 208000000X | Pediatrics Physician | — | NULL | — |
| 208000000X | Pediatrics Physician | — | — | — |
| 208600000X | Surgery Physician | — | NULL | — |
| 208600000X | Surgery Physician | — | — | — |
| 363A00000X | Physician Assistant | — | NULL | — |
| 363A00000X | Physician Assistant | — | — | — |
| 363LF0000X | Family Nurse Practitioner | — | NULL | — |
| 363LF0000X | Family Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 02/23/2009
- **Last updated:** 10/01/2024