Healthcare Provider Details

I. General information

NPI: 1144356288
Provider Name (Legal Business Name): KELLY JEANNE KOZLOWSKI DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2007
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19401 HUBBARD DR
DEARBORN MI
48126-2641
US

IV. Provider business mailing address

16878 ORCHARD GARDENS DR
MACOMB MI
48042-1195
US

V. Phone/Fax

Practice location:
  • Phone: 313-982-8261
  • Fax:
Mailing address:
  • Phone: 313-623-4707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101016832
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: