Basic Information
| Provider Information | |||||||||
| NPI: | 1235336199 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOWALSKI | ||||||||
| FirstName: | TADEUS | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1928 | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363021928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938087 | ||||||||
| FaxNumber: | 3347938191 | ||||||||
| Practice Location | |||||||||
| Address1: | 1108 ROSS CLARK CIR | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363013022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938087 | ||||||||
| FaxNumber: | 3347938191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2007 | ||||||||
| LastUpdateDate: | 08/06/2013 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | 098882 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 207R00000X | 24492 | WV | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2084P0800X | 32694 | AL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 098882 | 01 | OH | STATE MEDICAL BOARD | OTHER | 24492 | 01 | WV | STATE MEDICAL BOARD | OTHER |