Healthcare Provider Details

I. General information

NPI: 1962452748
Provider Name (Legal Business Name): EDWARD H KOWALESKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13640 N PLAZA DEL RIO BLVD STE 350
PEORIA AZ
85381-4846
US

IV. Provider business mailing address

13640 N PLAZA DEL RIO BLVD
PEORIA AZ
85381-4846
US

V. Phone/Fax

Practice location:
  • Phone: 623-876-8600
  • Fax: 623-876-6992
Mailing address:
  • Phone: 623-876-3800
  • Fax: 623-876-6992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16098
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: