Healthcare Provider Details

I. General information

NPI: 1528064201
Provider Name (Legal Business Name): KEITH A KOWAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20308 BEECHER ST
FAIRHOPE AL
36532-3692
US

IV. Provider business mailing address

1851 N MCKENZIE ST STE 106
FOLEY AL
36535-4704
US

V. Phone/Fax

Practice location:
  • Phone: 404-432-2391
  • Fax:
Mailing address:
  • Phone: 251-943-1117
  • Fax: 251-943-1183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number036199
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberMD.34240
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: