Healthcare Provider Details

I. General information

NPI: 1720173875
Provider Name (Legal Business Name): WALLACE KOWALCZYK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 OLD COURT RD
RANDALLSTOWN MD
21133-5103
US

IV. Provider business mailing address

66 POWERHOUSE RD 3RD FLOOR
ROSLYN HEIGHTS NY
11577-1324
US

V. Phone/Fax

Practice location:
  • Phone: 410-521-2200
  • Fax: 410-655-7190
Mailing address:
  • Phone: 516-945-3000
  • Fax: 516-945-3131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberD0016741
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: