Provider Demographics
NPI:1326043316
Name:KOWALCHICK, EDMUND JOSEPH JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:JOSEPH
Last Name:KOWALCHICK
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44250 GARFIELD RD
Mailing Address - Street 2:STE 160
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1150
Mailing Address - Country:US
Mailing Address - Phone:586-228-2255
Mailing Address - Fax:586-228-2740
Practice Address - Street 1:44250 GARFIELD RD
Practice Address - Street 2:STE 160
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1150
Practice Address - Country:US
Practice Address - Phone:586-228-2255
Practice Address - Fax:586-228-2740
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIEK001446213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI102448OtherPREFERRED/CARE CHOICES
MI4118378OtherAETNA
MI4616834Medicaid
MIU11976OtherHEALTH ALLIANCE PLAN
MI4855050170OtherBLUE CARE NETWORK
MI4616834OtherMOLINA
MI1221070004OtherWELLNESS
MIC1995OtherMCARE
MIP00141753OtherRAILROAD MEDICARE
MI1302112002OtherCIGNA
MI104183OtherGREAT LAKES HEALTH PLAN
MI4855050170OtherBLUE CROSS BLUE SHIELD
MI201094969OtherTIN
MI104183OtherGREAT LAKES HEALTH PLAN
MIC1995OtherMCARE
MIU11976Medicare UPIN
MI4616834Medicaid
MI0N94990Medicare PIN