1154693760 NPI number — MRS. MARYANNE MARGARET KOZAK P.T.

Table of content: MRS. MARYANNE MARGARET KOZAK P.T. (NPI 1154693760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154693760 NPI number — MRS. MARYANNE MARGARET KOZAK P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOZAK
Provider First Name:
MARYANNE
Provider Middle Name:
MARGARET
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GILBERT
Provider Other First Name:
MARYANNE
Provider Other Middle Name:
MARGARET
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.T.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154693760
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 REISTERSTOWN RD
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
PIKESVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21208-5105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-415-5374
Provider Business Mailing Address Fax Number:
410-415-5375

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 REISTERSTOWN RD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
PIKESVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21208-5105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-415-5374
Provider Business Practice Location Address Fax Number:
410-415-5375
Provider Enumeration Date:
01/30/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  21257 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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