Healthcare Provider Details

I. General information

NPI: 1689255028
Provider Name (Legal Business Name): MARY ELIZABETH COPELAND KOZAK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ELIZABETH COPELAND DO

II. Dates (important events)

Enumeration Date: 04/17/2021
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ST MARYS EPWORTH XING # A200
NEWBURGH IN
47630-9497
US

IV. Provider business mailing address

375 N WALL ST STE P310
KANKAKEE IL
60901-3484
US

V. Phone/Fax

Practice location:
  • Phone: 812-485-6030
  • Fax: 812-485-6032
Mailing address:
  • Phone: 815-933-0194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02008517A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036166884
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: