Healthcare Provider Details

I. General information

NPI: 1720306590
Provider Name (Legal Business Name): RACHEL ADE KOZICZKOWSKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 36TH AVE
MOLINE IL
61265-7159
US

IV. Provider business mailing address

870 36TH AVE
MOLINE IL
61265-7159
US

V. Phone/Fax

Practice location:
  • Phone: 309-623-7100
  • Fax: 309-623-7079
Mailing address:
  • Phone: 309-623-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036.140268
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: