Healthcare Provider Details

I. General information

NPI: 1346264124
Provider Name (Legal Business Name): LISE S KOWALSKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. LISE S THIBODEAU

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 08/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 FISHER RD SUITE 3-1
BERLIN VT
05602-9516
US

IV. Provider business mailing address

94 WEST HILL RD
WORCESTER VT
05682
US

V. Phone/Fax

Practice location:
  • Phone: 802-225-7000
  • Fax:
Mailing address:
  • Phone: 802-225-7047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number420008605
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: