Basic Information
| Provider Information | |||||||||
| NPI: | 1912933607 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOSSEIM | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3801 FILBERT ST | ||||||||
| Address2: | MAB, SUITE 102 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191042640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156629990 | ||||||||
| FaxNumber: | 2152433297 | ||||||||
| Practice Location | |||||||||
| Address1: | 3801 FILBERT ST | ||||||||
| Address2: | MAB, SUITE 102 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191042640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156629990 | ||||||||
| FaxNumber: | 2152433297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 12/08/2017 | ||||||||
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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 | 207R00000X | MD060366L | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD060366L | PA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 0016413140002 | 05 | PA | MEDICAID |