Healthcare Provider Details

I. General information

NPI: 1063774370
Provider Name (Legal Business Name): STACY JO KOWALSKY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 12/27/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 METROHEALTH DR
CLEVELAND OH
44109-1900
US

IV. Provider business mailing address

2500 METROHEALTH DR
CLEVELAND OH
44109-1900
US

V. Phone/Fax

Practice location:
  • Phone: 216-778-7800
  • Fax:
Mailing address:
  • Phone: 216-778-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35.142996
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMT201465
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number35.142996
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: