Provider Demographics
NPI:1205112240
Name:MARK T. KOWAL MD PC
Entity type:Organization
Organization Name:MARK T. KOWAL MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:KOWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-451-5507
Mailing Address - Street 1:1919 LATHROP ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5937
Mailing Address - Country:US
Mailing Address - Phone:907-451-5507
Mailing Address - Fax:907-451-5590
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:SUITE 202
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-451-5507
Practice Address - Fax:907-451-5590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-21
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK7319261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center