Healthcare Provider Details

I. General information

NPI: 1912649849
Provider Name (Legal Business Name): DOMINIK ADAM KOWALCZYK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N RITTER AVE
INDIANAPOLIS IN
46219-3027
US

IV. Provider business mailing address

7152 BELL ST
SCHERERVILLE IN
46375-3528
US

V. Phone/Fax

Practice location:
  • Phone: 317-355-1411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number11022226A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01096390A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: