Healthcare Provider Details

I. General information

NPI: 1013423003
Provider Name (Legal Business Name): SCOTT KOWALEWSKY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 12/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 COLUMBUS AVE
BAY CITY MI
48708-6831
US

IV. Provider business mailing address

1234 DETTLOFF ST
ROGERS CITY MI
49779-1255
US

V. Phone/Fax

Practice location:
  • Phone: 989-894-3000
  • Fax:
Mailing address:
  • Phone: 989-351-0729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704290119
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: