Provider Demographics
NPI:1164433546
Name:POVICH, MARK A (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:POVICH
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:3409 LUDINGTON ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-4212
Mailing Address - Country:US
Mailing Address - Phone:906-786-5707
Mailing Address - Fax:906-789-4430
Practice Address - Street 1:3409 LUDINGTON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-4212
Practice Address - Country:US
Practice Address - Phone:906-786-5707
Practice Address - Fax:906-789-4430
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MI5101009167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3294610Medicaid
F87877Medicare UPIN