Basic Information
| Provider Information | |||||||||
| NPI: | 1255329504 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOSHI | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | PALACHICACKA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1290 GOLFVIEW AVE | ||||||||
| Address2: | 4TH FLOOR ATTN: BILLING DEPARTMENT | ||||||||
| City: | BARTOW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338306738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635197900 | ||||||||
| FaxNumber: | 8635197696 | ||||||||
| Practice Location | |||||||||
| Address1: | 1805 HOBBS RD | ||||||||
| Address2: | |||||||||
| City: | AUBURNDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338234644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8639655400 | ||||||||
| FaxNumber: | 8639653739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 08/11/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME209029 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 069749400 | 05 | FL | MEDICAID |