1730170697 NPI number — PATRICIA M KOWALSKI OD

Table of content: PATRICIA M KOWALSKI OD (NPI 1730170697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730170697 NPI number — PATRICIA M KOWALSKI OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOWALSKI
Provider First Name:
PATRICIA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730170697
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 COOLIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48823-1378
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-337-1668
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 W LAKE LANSING RD
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
EAST LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48823-8526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-337-1668
Provider Business Practice Location Address Fax Number:
517-337-1779
Provider Enumeration Date:
10/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  TU006490-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 4901004417 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200000010078 . This is a "PPHPMM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: PK004417 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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