Healthcare Provider Details

I. General information

NPI: 1073174108
Provider Name (Legal Business Name): EVAN CONNOR KOWALSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2019
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 E PARIS AVE SE STE 100
GRAND RAPIDS MI
49546-6113
US

IV. Provider business mailing address

2060 E PARIS AVE SE STE 100
GRAND RAPIDS MI
49546-6113
US

V. Phone/Fax

Practice location:
  • Phone: 616-956-6100
  • Fax:
Mailing address:
  • Phone: 616-956-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35.150576
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4351045607
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: