MEDICARE: DR. TERRY KOWALENKO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	4301058183	MI
2	207P00000X	Emergency Medicine Physician	81850	SC
3	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician	058183	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	TK058183	OTHER	MI	BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023045085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRY KOWALENKO M.D.

Provider Business Mailing Address
First Line	:	PO BOX 751461
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28275-1461
Country	:	US
Telephone Number	:	843-792-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	171 ASHLEY AVE
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29425-6712
Country	:	US
Telephone Number	:	843-792-1414
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	01/14/2019

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