Provider Demographics
NPI:1992115638
Name:KOWNACKI, KYLE A (MD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:A
Last Name:KOWNACKI
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 1:121 S SAINT LOUIS BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2924
Mailing Address - Country:US
Mailing Address - Phone:574-233-3123
Mailing Address - Fax:
Practice Address - Street 1:5215 HOLY CROSS PKWY
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1469
Practice Address - Country:US
Practice Address - Phone:574-335-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01078539A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology