Healthcare Provider Details

I. General information

NPI: 1023664257
Provider Name (Legal Business Name): EMILY ROSE KOWAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 W JACKSON BLVD STE 200
CHICAGO IL
60612-3227
US

IV. Provider business mailing address

600 S PAULINA ST STE 403
CHICAGO IL
60612-3806
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-2200
  • Fax:
Mailing address:
  • Phone: 312-942-5495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125081209
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: