Provider Demographics
NPI:1629405063
Name:KOZIOL, RADOSLAW
Entity Type:Individual
Prefix:
First Name:RADOSLAW
Middle Name:
Last Name:KOZIOL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-2584
Mailing Address - Country:US
Mailing Address - Phone:847-962-1923
Mailing Address - Fax:
Practice Address - Street 1:5001 MADISON ST
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-2584
Practice Address - Country:US
Practice Address - Phone:847-962-1923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL13752724208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL13752724OtherPRODUSER NUMBER