Healthcare Provider Details

I. General information

NPI: 1023559218
Provider Name (Legal Business Name): EUGENE MICHAEL COZZA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 E ONTARIO ST STE 7-100
CHICAGO IL
60611-4418
US

IV. Provider business mailing address

446 E ONTARIO ST STE 7-100
CHICAGO IL
60611-4418
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-5060
  • Fax: 312-926-7612
Mailing address:
  • Phone: 312-695-5060
  • Fax: 312-926-7612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036150852
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: