Provider Demographics
NPI:1548930431
Name:KOSOW, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:KOSOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2342 W BLOOMINGDALE AVE APT 403
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5616
Mailing Address - Country:US
Mailing Address - Phone:603-965-5456
Mailing Address - Fax:
Practice Address - Street 1:4400 W 95TH ST STE 413
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2662
Practice Address - Country:US
Practice Address - Phone:708-346-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.008163363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant