Provider Demographics
NPI:1063472389
Name:KOVALICK, MICHAEL A (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:KOVALICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-3034
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:114 LT MICHAEL CLEARY DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:PA
Practice Address - Zip Code:18612-1649
Practice Address - Country:US
Practice Address - Phone:570-675-2000
Practice Address - Fax:570-675-1806
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009120L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001705959Medicaid
PA013933Medicare ID - Type Unspecified