Healthcare Provider Details

I. General information

NPI: 1780739102
Provider Name (Legal Business Name): HENRY JOHN KOWALSKI SR. M.D,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 N MILWAUKEE AVE STE D
CHICAGO IL
60646-5400
US

IV. Provider business mailing address

5901 N MILWAUKEE AVE STE D
CHICAGO IL
60646-5400
US

V. Phone/Fax

Practice location:
  • Phone: 773-631-1300
  • Fax: 773-631-3971
Mailing address:
  • Phone: 773-631-1300
  • Fax: 773-631-3971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: