Healthcare Provider Details

I. General information

NPI: 1821489097
Provider Name (Legal Business Name): MATTHEW JOHN KOSCICA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 07/24/2020
Certification Date: 07/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 E WASHINGTON ST STE 1464
CHICAGO IL
60602-1820
US

IV. Provider business mailing address

25 E WASHINGTON ST STE 1464
CHICAGO IL
60602-1820
US

V. Phone/Fax

Practice location:
  • Phone: 312-600-7818
  • Fax: 765-204-1880
Mailing address:
  • Phone: 312-600-7818
  • Fax: 765-204-1880

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number125068293
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.147145
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: