Provider Demographics
NPI:1003855719
Name:KOVACHEVICH, MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:KOVACHEVICH
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 1:2650 RIDGE AVE
Mailing Address - Street 2:EVANSTON HOSPITAL RM 1210
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-1206
Mailing Address - Fax:847-570-1248
Practice Address - Street 1:2050 PFINGSTEN RD
Practice Address - Street 2:SUITE 330
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1324
Practice Address - Country:US
Practice Address - Phone:847-998-4100
Practice Address - Fax:847-998-8439
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055036207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
584340Medicare ID - Type Unspecified
D16116Medicare UPIN