Basic Information
| Provider Information | |||||||||
| NPI: | 1467479808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOWALSKI | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1717 | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272161717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365381234 | ||||||||
| FaxNumber: | 3365382390 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 HUFFMAN MILL RD | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272158700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365381234 | ||||||||
| FaxNumber: | 3365382390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 01/30/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 97-00624 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 8910494 | 05 | NC | MEDICAID |