Healthcare Provider Details

I. General information

NPI: 1578652632
Provider Name (Legal Business Name): KATHRYN M KOZAK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 02/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ON025 WINFIELD RD.
WINFIELD IL
60190
US

IV. Provider business mailing address

255 W MICHIGAN AVE
JACKSON MI
49201-2218
US

V. Phone/Fax

Practice location:
  • Phone: 630-933-1600
  • Fax: 517-787-4146
Mailing address:
  • Phone: 517-787-6440
  • Fax: 517-787-4146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036080118
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: