Healthcare Provider Details

I. General information

NPI: 1396711875
Provider Name (Legal Business Name): JOHN OSCAR KOWALSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5669 W. 95TH ST.
OAK LAWN IL
60453-6501
US

IV. Provider business mailing address

5669 W. 95TH ST
OAK LAWN IL
60453-6501
US

V. Phone/Fax

Practice location:
  • Phone: 708-499-4400
  • Fax: 708-499-4407
Mailing address:
  • Phone: 708-499-4400
  • Fax: 708-499-4407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-075588
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: