Basic Information
| Provider Information | |||||||||
| NPI: | 1205168770 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOCZMAN | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | EMORY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EMORY | ||||||||
| OtherFirstName: | MICHELE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4400 W 95TH ST | ||||||||
| Address2: | STE 308 | ||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604532660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083464040 | ||||||||
| FaxNumber: | 7083463287 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 BIESTERFIELD RD STE 545 | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600073362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475934116 | ||||||||
| FaxNumber: | 8475934135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2010 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085.007232 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.