1336187905 NPI number — MRS. ELIZABETH ANN HEIDT KOZISEK PH D

Table of content: MRS. ELIZABETH ANN HEIDT KOZISEK PH D (NPI 1336187905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336187905 NPI number — MRS. ELIZABETH ANN HEIDT KOZISEK PH D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEIDT KOZISEK
Provider First Name:
ELIZABETH
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PH D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HEIDT
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH D
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1336187905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 65
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST. LIBORY
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68872-0065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-379-1949
Provider Business Mailing Address Fax Number:
308-687-6309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1932 ASPEN CIRCLE
Provider Second Line Business Practice Location Address:
SUITE J
Provider Business Practice Location Address City Name:
GRAND ISLAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-379-1949
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/03/2006

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: 103T00000X , with the licence number:  451 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 451 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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