Healthcare Provider Details

I. General information

NPI: 1235178708
Provider Name (Legal Business Name): JOHN ALLEN KOWALSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W HARRISON ST SUITE 1266
CHICAGO IL
60612-3741
US

IV. Provider business mailing address

1301 W MADISON ST UNIT 523
CHICAGO IL
60607-1936
US

V. Phone/Fax

Practice location:
  • Phone: 312-572-4739
  • Fax: 312-572-4719
Mailing address:
  • Phone: 312-666-5753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number036053307
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: