Provider Demographics
NPI:1265494595
Name:KOVAN, BRUCE S (DO)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:S
Last Name:KOVAN
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 1:37399 GARFIELD RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-3672
Mailing Address - Country:US
Mailing Address - Phone:586-286-5400
Mailing Address - Fax:586-263-4831
Practice Address - Street 1:37399 GARFIELD RD
Practice Address - Street 2:SUITE 104
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-3672
Practice Address - Country:US
Practice Address - Phone:586-286-5400
Practice Address - Fax:586-263-4831
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008312207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1730497Medicaid
E06378003Medicare ID - Type Unspecified
MI1730497Medicaid