MEDICARE: RADOSLAW KOZIOL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	13752724	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	13752724	OTHER	IL	PRODUSER NUMBER

General Provider Information

NPI Number	:	1629405063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RADOSLAW KOZIOL

Provider Business Mailing Address
First Line	:	5001 MADISON ST
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60077-2584
Country	:	US
Telephone Number	:	847-962-1923
Fax Number	:

Provider Business Practice Location Address
First Line	:	5001 MADISON ST
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60077-2584
Country	:	US
Telephone Number	:	847-962-1923
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2013
Last Update Date	:	09/30/2013

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