Provider Demographics
NPI:1003866161
Name:NOWACKI, BERNARD HAROLD (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:HAROLD
Last Name:NOWACKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:# L-3652
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43260-6453
Mailing Address - Country:US
Mailing Address - Phone:740-383-7927
Mailing Address - Fax:740-383-7942
Practice Address - Street 1:1040 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6416
Practice Address - Country:US
Practice Address - Phone:740-383-8070
Practice Address - Fax:740-383-3695
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35047204207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0488459Medicaid
A15136Medicare UPIN
OH0488459Medicaid
OHNO0514161Medicare ID - Type Unspecified