1891729166 NPI number — SCOTT M KOWALSKI DO

Table of content: SCOTT M KOWALSKI DO (NPI 1891729166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891729166 NPI number — SCOTT M KOWALSKI DO

Organization/Personal Information

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

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:
1891729166
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3717 WESTOVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLEMING ISLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32003-7107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-896-1375
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1564 KINGSLEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32073-4521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-264-8801
Provider Business Practice Location Address Fax Number:
904-621-0566
Provider Enumeration Date:
07/10/2006

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: 208100000X , with the licence number:  5101016005 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081P2900X , with the licence number: OS16975 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 108927900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1891729166 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 108927900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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