MEDICARE: DR. GREGORY NICHOLAS KOZLOV DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	036.127771	IL
2	207LP2900X	Pain Medicine (Anesthesiology) Physician	036.127771	IL

General Provider Information

NPI Number	:	1205006277
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY NICHOLAS KOZLOV DO

Provider Business Mailing Address
First Line	:	204 37TH AVE N
Second Line	:	SUITE 125
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33704-1416
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	204 37TH AVE N
Second Line	:	SUITE 125
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33704-1416
Country	:	US
Telephone Number	:	727-331-2457
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2008
Last Update Date	:	02/21/2014

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