Healthcare Provider Details

I. General information

NPI: 1972698223
Provider Name (Legal Business Name): MARY-ANNE OTTILIE KOWOL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 N MAYFAIR RD DEPARTMENT OF PSYCHIATRY
MILWAUKEE WI
53226-3462
US

IV. Provider business mailing address

1155 N MAYFAIR RD DEPARTMENT OF PSYCHIATRY
MILWAUKEE WI
53226-3462
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-8990
  • Fax: 414-955-6299
Mailing address:
  • Phone: 414-955-8990
  • Fax: 414-955-6299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number28168
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number50941
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: