Provider Demographics
NPI:1629168489
Name:KOZICZ, KEVIN A (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:KOZICZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14476 PARALLEL AVE
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-7988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 W CHISHOLM ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1401
Practice Address - Country:US
Practice Address - Phone:989-356-7390
Practice Address - Fax:989-356-8013
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072813207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4471880Medicaid
MI0500410122OtherBCBS MICHIGAN
MIP00108494OtherRAILROAD MEDICARE
MI4471880Medicaid
MIP00108494OtherRAILROAD MEDICARE