Basic Information
| Provider Information | |||||||||
| NPI: | 1659040020 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOZLOW | ||||||||
| FirstName: | MAUREEN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8558 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193927084 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 S LAKE PARK AVE STE 110 | ||||||||
| Address2: | |||||||||
| City: | HOBART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463426638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199476017 | ||||||||
| FaxNumber: | 2199476018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2021 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 00000000A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 10003398A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 300054941 | 05 | IN | MEDICAID |