Provider Demographics
NPI:1174613699
Name:COWLES, SALLY R (MD)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:R
Last Name:COWLES
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 1:1903 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-5200
Mailing Address - Country:US
Mailing Address - Phone:269-387-3290
Mailing Address - Fax:269-387-2944
Practice Address - Street 1:1903 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-5200
Practice Address - Country:US
Practice Address - Phone:269-387-3290
Practice Address - Fax:269-387-2944
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301029642208D00000X, 2083P0901X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0C94735OtherBCBS
MIH09334Medicare UPIN