Provider Demographics
NPI:1295766772
Name:KOWALSKI, LISA A (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:KOWALSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 S SIXTH
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:217-528-8962
Practice Address - Street 1:300 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2003
Practice Address - Country:US
Practice Address - Phone:217-342-4151
Practice Address - Fax:217-347-3033
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095601208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL080098315OtherRAILROAD MEDICARE #
IL338596OtherHEALTHLINK #
IL036095601Medicaid
IL14D0902430OtherEFFINGHAM CLIA #
IL2523659OtherBC/BS #
IL088127001OtherEFFINGHAM DMEPOS #
ILG53573Medicare UPIN
IL347560Medicare PIN
IL055388OtherHEALTH ALLIANCE #