Provider Demographics
NPI:1114924248
Name:KOVALSZKI, PETER A (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:KOVALSZKI
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 1:133 S MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2308
Mailing Address - Country:US
Mailing Address - Phone:586-465-1326
Mailing Address - Fax:586-465-0329
Practice Address - Street 1:133 S MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2308
Practice Address - Country:US
Practice Address - Phone:586-465-1326
Practice Address - Fax:586-465-0329
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052134174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI267880Medicaid
MI267880Medicaid
MIF07127Medicare UPIN