Healthcare Provider Details

I. General information

NPI: 1760657357
Provider Name (Legal Business Name): ROZA KOSTECKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 05/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 SOUTHRIDGE TRL
ALGONQUIN IL
60102-6607
US

IV. Provider business mailing address

1550 SOUTHRIDGE TRL
ALGONQUIN IL
60102-6607
US

V. Phone/Fax

Practice location:
  • Phone: 847-428-9629
  • Fax: 847-844-3848
Mailing address:
  • Phone: 847-428-9629
  • Fax: 847-844-3848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number92574
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: