Healthcare Provider Details

I. General information

NPI: 1326043316
Provider Name (Legal Business Name): EDMUND JOSEPH KOWALCHICK JR. DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44250 GARFIELD RD STE 160
CLINTON TOWNSHIP MI
48038-1150
US

IV. Provider business mailing address

44250 GARFIELD RD STE 160
CLINTON TOWNSHIP MI
48038-1150
US

V. Phone/Fax

Practice location:
  • Phone: 586-228-2255
  • Fax: 586-228-2740
Mailing address:
  • Phone: 586-228-2255
  • Fax: 586-228-2740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberEK001446
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901001446
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: