Healthcare Provider Details

I. General information

NPI: 1629405063
Provider Name (Legal Business Name): RADOSLAW KOZIOL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2013
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 MADISON ST
SKOKIE IL
60077-2584
US

IV. Provider business mailing address

5001 MADISON ST
SKOKIE IL
60077-2584
US

V. Phone/Fax

Practice location:
  • Phone: 847-962-1923
  • Fax:
Mailing address:
  • Phone: 847-962-1923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number13752724
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: