Healthcare Provider Details

I. General information

NPI: 1962556340
Provider Name (Legal Business Name): GEORGE HANCOCK KOWALLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 W 56TH ST SUITE 407
NEW YORK NY
10019-3831
US

IV. Provider business mailing address

162 W 56TH ST SUITE 407
NEW YORK NY
10019-3831
US

V. Phone/Fax

Practice location:
  • Phone: 212-757-0324
  • Fax: 212-757-0324
Mailing address:
  • Phone: 212-757-0324
  • Fax: 212-757-0324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD115904-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD115904-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: