Healthcare Provider Details

I. General information

NPI: 1043530025
Provider Name (Legal Business Name): MICHAEL VINCENT KOWAL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 SPRING STREET
RACINE WI
53405
US

IV. Provider business mailing address

474 N LAKE SHORE DR UNIT 2311
CHICAGO IL
60611-3400
US

V. Phone/Fax

Practice location:
  • Phone: 262-687-4011
  • Fax:
Mailing address:
  • Phone: 847-204-0690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number61558-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: