Healthcare Provider Details

I. General information

NPI: 1992774087
Provider Name (Legal Business Name): ROMAN M KOWALCHUK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE
ROCHESTER NY
14621-3001
US

IV. Provider business mailing address

1425 PORTLAND AVE
ROCHESTER NY
14621-3001
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-3220
  • Fax: 585-922-3518
Mailing address:
  • Phone: 585-922-3220
  • Fax: 585-922-3518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number210880
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: