Basic Information
| Provider Information | |||||||||
| NPI: | 1720173875 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOWALCZYK | ||||||||
| FirstName: | WALLACE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 POWERHOUSE RD | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | ROSLYN HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115771324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453000 | ||||||||
| FaxNumber: | 5169453131 | ||||||||
| Practice Location | |||||||||
| Address1: | 5401 OLD COURT RD | ||||||||
| Address2: | |||||||||
| City: | RANDALLSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211335103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105212200 | ||||||||
| FaxNumber: | 4106557190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | D0016741 | MD | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 454MH696 | 01 | MD | TRAILBLAZER | OTHER |