Basic Information
| Provider Information | |||||||||
| NPI: | 1750597654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOZIC | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 CHESTNUT ST | ||||||||
| Address2: | SUITE 740 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556680 | ||||||||
| FaxNumber: | 2155032556 | ||||||||
| Practice Location | |||||||||
| Address1: | 833 CHESTNUT ST | ||||||||
| Address2: | SUITE 740 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556680 | ||||||||
| FaxNumber: | 2155032556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 10/09/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | C1-0008613 | DE | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | MT181819 | PA | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | MD432113 | PA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 102055628 | 05 | PA | MEDICAID | 0351610 | 05 | NJ | MEDICAID |