Healthcare Provider Details

I. General information

NPI: 1548558778
Provider Name (Legal Business Name): PETER KOZLOWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2011
Last Update Date: 11/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 TURNER AVE
ELK GROVE VILLAGE IL
60007-3931
US

IV. Provider business mailing address

90 TURNER AVE
ELK GROVE VILLAGE IL
60007-3931
US

V. Phone/Fax

Practice location:
  • Phone: 847-626-5758
  • Fax:
Mailing address:
  • Phone: 847-626-5758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036134238
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: