1912908914 NPI number — WILLIAM J KOZAK JR. MD

Table of content: WILLIAM J KOZAK JR. MD (NPI 1912908914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912908914 NPI number — WILLIAM J KOZAK JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOZAK
Provider First Name:
WILLIAM
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912908914
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
506 ATHENA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELMONT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15626-1005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-468-6869
Provider Business Mailing Address Fax Number:
724-468-6207

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2620 MEMORIAL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONNELLSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15425-1488
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-626-0700
Provider Business Practice Location Address Fax Number:
724-626-8700
Provider Enumeration Date:
08/02/2005

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: 207Q00000X , with the licence number:  MD422207 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0019646830002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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