Basic Information
| Provider Information | |||||||||
| NPI: | 1740282797 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOWALSKI | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | VICTOR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 W ILES AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627047015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176983030 | ||||||||
| FaxNumber: | 2176983068 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 W MORTON AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626502623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172456814 | ||||||||
| FaxNumber: | 2172450375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2005 | ||||||||
| LastUpdateDate: | 02/03/2016 | ||||||||
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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 | 207W00000X | 053472 | GA | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 200301373 | NC | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 036079360 | IL | Y | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 336042367 | IL | N | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 141F1 | 01 | NC | BCBS PROV # | OTHER | 33079 | 01 | OPTICARE PROVIDER NUMBER | OTHER | P00395184 | 01 | RR MEDICARE PROV. NUMBER | OTHER | 5902639 | 05 | NC | MEDICAID | 807073 | 01 | NC | PARTNERS PROV NUMBER | OTHER |