Provider Demographics
NPI: | 1144394206 |
---|---|
Name: | POPOVICH, PETER J (DO) |
Entity Type: | Individual |
Prefix: | |
First Name: | PETER |
Middle Name: | J |
Last Name: | POPOVICH |
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: | PO BOX 950112 |
Mailing Address - Street 2: | DEPT. 52387 |
Mailing Address - City: | LOUISVILLE |
Mailing Address - State: | KY |
Mailing Address - Zip Code: | 40295-0112 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 866-965-3774 |
Mailing Address - Fax: | 781-276-6411 |
Practice Address - Street 1: | 913 N DIXIE AVE |
Practice Address - Street 2: | |
Practice Address - City: | ELIZABETHTOWN |
Practice Address - State: | KY |
Practice Address - Zip Code: | 42701-2503 |
Practice Address - Country: | US |
Practice Address - Phone: | 877-783-6257 |
Practice Address - Fax: | 859-514-5521 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-11-20 |
Last Update Date: | 2016-10-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | M5446 | 207P00000X |
KY | 03164 | 207P00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | P00650256 | Other | RAILROAD |
TX | 188382902 | Medicaid | |
TX | 8AA314 | Other | BCBS |
TX | 8W1785 | Other | BCBS |
TX | 8W1785 | Other | BCBS |
MO | F91129 | Medicare UPIN | |
KY | 0694548 | Medicare PIN |