Basic Information
| Provider Information | |||||||||
| NPI: | 1215915301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOW | ||||||||
| FirstName: | AVIS | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 MILK ST | ||||||||
| Address2: | PROVIDER ENROLLMENT - 9TH FLOOR | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021094806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175598053 | ||||||||
| FaxNumber: | 6174213487 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 ESSEX CENTER DR | ||||||||
| Address2: | |||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019602902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789774000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35106 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | K19122 | 01 | MA | BLUE CROSS | OTHER | PV373 | 01 | MA | HARVARD PILGRIM | OTHER | 0015275 | 01 | MA | NEIGHBORHOOD HEALTH | OTHER | B10452102 | 01 | MA | CIGNA | OTHER | 3083578 | 05 | MA | MEDICAID | 794897 | 01 | MA | TUFTS | OTHER |