=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740282797
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL VICTOR KOWALSKI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2005
-----------------------------------------------------
Last Update Date | 02/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 W MORTON AVE
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62650-2623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-245-6814
-----------------------------------------------------
Fax | 217-245-0375
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2020 W ILES AVE
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62704-7015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-698-3030
-----------------------------------------------------
Fax | 217-698-3068
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 053472
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 200301373
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 036079360
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 336042367
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------