Basic Information
| Provider Information | |||||||||
| NPI: | 1134166879 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOZLOFF | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27702 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088627674 | ||||||||
| FaxNumber: | 7088621781 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 W 156TH ST | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | HARVEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604264260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083394800 | ||||||||
| FaxNumber: | 7083393760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 09/25/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 01038049A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | IL036047581 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 036047581 | 05 | IL | MEDICAID | 200016510F | 05 | IN | MEDICAID |