Provider Demographics
NPI:1760657357
Name:KOSTECKI, ROZA
Entity type:Individual
Prefix:
First Name:ROZA
Middle Name:
Last Name:KOSTECKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 SOUTHRIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-6607
Mailing Address - Country:US
Mailing Address - Phone:847-428-9629
Mailing Address - Fax:847-844-3848
Practice Address - Street 1:1550 SOUTHRIDGE TRL
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-6607
Practice Address - Country:US
Practice Address - Phone:847-428-9629
Practice Address - Fax:847-844-3848
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL925742471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1563Medicare PIN