Basic Information
| Provider Information | |||||||||
| NPI: | 1245466036 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOWALCHUK | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6335 HOSPITAL PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | JOHNS CREEK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300971549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045754500 | ||||||||
| FaxNumber: | 4045754555 | ||||||||
| Practice Location | |||||||||
| Address1: | 6335 HOSPITAL PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | JOHNS CREEK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300971549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045754500 | ||||||||
| FaxNumber: | 4045754555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2009 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 241059 | MA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0004X | Q0092 | TX | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207X00000X | 073800 | GA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 003168359A | 05 | GA | MEDICAID |