Provider Demographics
NPI:1407998602
Name:ROMAN OREST KOZYCKYJ
Entity Type:Organization
Organization Name:ROMAN OREST KOZYCKYJ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-229-2240
Mailing Address - Street 1:4700 W 95TH ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2533
Mailing Address - Country:US
Mailing Address - Phone:708-229-2240
Mailing Address - Fax:708-229-2494
Practice Address - Street 1:4700 W 95TH ST
Practice Address - Street 2:SUITE 206
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2533
Practice Address - Country:US
Practice Address - Phone:708-229-2240
Practice Address - Fax:708-229-2494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01625872OtherBLUE CROSS BLUE SHIELD
IL393300Medicare ID - Type Unspecified
ILD14807Medicare UPIN