=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689043515
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENT CENTERS OF EXCELLENCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2015
-----------------------------------------------------
Last Update Date | 03/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1851 N MCKENZIE ST SUITE 106
-----------------------------------------------------
City | FOLEY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36535-4700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-943-1117
-----------------------------------------------------
Fax | 251-943-1183
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1851 N MCKENZIE ST SUITE 106
-----------------------------------------------------
City | FOLEY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36535-4700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-943-1117
-----------------------------------------------------
Fax | 251-943-1183
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PYSICIAN
-----------------------------------------------------
Name | KEITH A. KOWAL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 251-943-1117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------