Provider Demographics
NPI:1184636532
Name:KOWALCHUK, GLEN J (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:J
Last Name:KOWALCHUK
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9625 NORTHCROSS CENTER CT
Practice Address - Street 2:STE 102
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7348
Practice Address - Country:US
Practice Address - Phone:704-403-2860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC37877207R00000X, 207RI0011X, 207RC0000X, 207RI0011X, 207RC0000X
SC14624207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC146247Medicaid
NC1184636532Medicaid
NC8950297Medicaid
P00214961OtherRAILROAD MEDICARE
NC50297OtherBCBS
NC1184636532Medicaid
P00214961OtherRAILROAD MEDICARE
NC8950297Medicaid