Provider Demographics
NPI:1245221621
Name:KOVACK, PAUL J (DO)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:J
Last Name:KOVACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:2122 HEALTH DR SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9698
Practice Address - Country:US
Practice Address - Phone:616-252-5950
Practice Address - Fax:616-252-5956
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011064207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI060037412OtherRAILROAD MEDICARE
MI5101011064OtherSTATE LICENSE
MI3222989Medicaid
MIPK011064OtherBSBCM PIN
MIG20931Medicare UPIN
MI3222989Medicaid