Provider Demographics
NPI:1386826592
Name:JOHN J KOVACICH MD
Entity Type:Organization
Organization Name:JOHN J KOVACICH MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:K
Authorized Official - Last Name:KOVACICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-372-2365
Mailing Address - Street 1:248 DOCTORS ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SPARTA
Mailing Address - State:NC
Mailing Address - Zip Code:28675-9247
Mailing Address - Country:US
Mailing Address - Phone:336-372-2481
Mailing Address - Fax:336-372-5143
Practice Address - Street 1:248 DOCTORS ST
Practice Address - Street 2:SUITE A
Practice Address - City:SPARTA
Practice Address - State:NC
Practice Address - Zip Code:28675-9247
Practice Address - Country:US
Practice Address - Phone:336-372-2481
Practice Address - Fax:336-372-5143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23588207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2311980Medicare PIN