Provider Demographics
NPI:1962556340
Name:KOWALLIS, GEORGE HANCOCK (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:HANCOCK
Last Name:KOWALLIS
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 1:162 W 56TH ST
Mailing Address - Street 2:SUITE 407
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-3831
Mailing Address - Country:US
Mailing Address - Phone:212-757-0324
Mailing Address - Fax:212-757-0324
Practice Address - Street 1:162 W 56TH ST
Practice Address - Street 2:SUITE 407
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3831
Practice Address - Country:US
Practice Address - Phone:212-757-0324
Practice Address - Fax:212-757-0324
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYMD115904-12084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY34886Medicare ID - Type Unspecified
NYB13537Medicare UPIN