Healthcare Provider Details

I. General information

NPI: 1780720250
Provider Name (Legal Business Name): GERALD JOSEPH KOZAK III MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GERRY KOZAK PT

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 S MAIN ST
ALMONT MI
48003-1066
US

IV. Provider business mailing address

24014 W RENWICK RD UNIT 206
PLAINFIELD IL
60544-8711
US

V. Phone/Fax

Practice location:
  • Phone: 800-974-4378
  • Fax: 630-515-1536
Mailing address:
  • Phone: 800-974-4378
  • Fax: 630-515-1536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberL951582
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501012904
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: