MEDICARE: STEPHEN HERBERT KOZLOWSKI M.D.

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	207RR0500X	Rheumatology Physician	036-053309	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0359580001	OTHER	IL	DMERC
2	01915167	OTHER	IL	BLUE CROSS/BLUE SHIELD
3	112318	OTHER	IL	HEALTH ALLIANCE

General Provider Information

NPI Number	:	1285749390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN HERBERT KOZLOWSKI M.D.

Provider Business Mailing Address
First Line	:	360 STATION DR
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-7978
Country	:	US
Telephone Number	:	815-338-6600
Fax Number	:

Provider Business Practice Location Address
First Line	:	360 STATION DR
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-7978
Country	:	US
Telephone Number	:	815-338-6600
Fax Number	:

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

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	07/21/2022

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