Basic Information
| Provider Information | |||||||||
| NPI: | 1952396210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOWAKOWSKI | ||||||||
| FirstName: | MACIEJ | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 346 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077622048 | ||||||||
| FaxNumber: | 6077623496 | ||||||||
| Practice Location | |||||||||
| Address1: | 93 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139031645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077622048 | ||||||||
| FaxNumber: | 6077623496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 05/01/2014 | ||||||||
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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 | 207RC0000X | 233376 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RS0012X | 233376 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02645509 | 05 | NY | MEDICAID | 2101351 | 05 | MA | MEDICAID |