MEDICARE: TERESA D KOWALCZYK MD

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	207VG0400X	Gynecology Physician	K4932	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	752941533	OTHER	TX	TAX IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1538170261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA D KOWALCZYK MD

Provider Business Mailing Address
First Line	:	4221 RIDGECREST
Second Line	:	SUITE 109
City	:	GREENVILLE
State	:	TX
Zip	:	75402
Country	:	US
Telephone Number	:	903-455-9582
Fax Number	:	903-455-5689

Provider Business Practice Location Address
First Line	:	4221 RIDGECREST RD
Second Line	:	SUITE 109
City	:	GREENVILLE
State	:	TX
Zip	:	75402-6005
Country	:	US
Telephone Number	:	903-455-9582
Fax Number	:	903-455-5689

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

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	07/08/2007

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