Healthcare Provider Details

I. General information

NPI: 1871485136
Provider Name (Legal Business Name): MICHAEL BENJAMIN KOWITZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2025
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 E 5TH AVE
ANTIGO WI
54409-2710
US

IV. Provider business mailing address

112 E 5TH AVE
ANTIGO WI
54409-2710
US

V. Phone/Fax

Practice location:
  • Phone: 715-623-9449
  • Fax:
Mailing address:
  • Phone: 715-623-9449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17382-024
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP046740T
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: