Basic Information
| Provider Information | |||||||||
| NPI: | 1538116835 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOWALSKI | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 POWELL ST | ||||||||
| Address2: | SUITE 920 | ||||||||
| City: | EMERYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946081826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103502777 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10010 KENNERLY RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145251000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 09/08/2015 | ||||||||
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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 | 207P00000X | 114693 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00691432 | 01 | RR MEDICARE | OTHER | 244748927 | 05 | MO | MEDICAID | 1538116835 | 05 | MO | MEDICAID |