Provider Demographics
NPI:1336128222
Name:KOVACH, MARK W (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:KOVACH
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 1:1230 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2704
Mailing Address - Country:US
Mailing Address - Phone:800-445-3501
Mailing Address - Fax:307-266-3177
Practice Address - Street 1:1230 E 1ST ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2704
Practice Address - Country:US
Practice Address - Phone:800-445-3501
Practice Address - Fax:307-266-3177
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098054207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00062332OtherMEDICARE RAILROAD
IL036098054Medicaid
IA2416040Medicaid
IAI10069Medicare PIN
F70889Medicare UPIN
IL036098054Medicaid