Basic Information
| Provider Information | |||||||||
| NPI: | 1356390439 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOWALCZUK | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 690 CANTON ST | ||||||||
| Address2: | SUITE 325 | ||||||||
| City: | WESTWOOD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020902321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814077713 | ||||||||
| FaxNumber: | 7814070998 | ||||||||
| Practice Location | |||||||||
| Address1: | 690 CANTON ST | ||||||||
| Address2: | SUITE 325 | ||||||||
| City: | WESTWOOD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020902321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814077713 | ||||||||
| FaxNumber: | 7814070998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 01/29/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 150212 | MA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 110058018A | 05 | MA | MEDICAID | J17300 | 01 | MA | BLUE CROSS/BLUE SHIELD | OTHER | 3161293 | 05 | MA | MEDICAID | 150212 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 277191 | 01 | MA | HARVARD PILGRIM HEALTHCAR | OTHER |