Provider Demographics
NPI:1558363309
Name:KOVACICH, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KOVACICH
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 1:9660 WICKER AVE
Mailing Address - Street 2:STE 100E
Mailing Address - City:ST JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9487
Mailing Address - Country:US
Mailing Address - Phone:219-365-1166
Mailing Address - Fax:219-365-8852
Practice Address - Street 1:9660 WICKER AVE
Practice Address - Street 2:STE 100E
Practice Address - City:ST JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9487
Practice Address - Country:US
Practice Address - Phone:219-365-1166
Practice Address - Fax:219-365-8852
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033371A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100212020Medicaid
IN000000375704OtherANTHEM
D69803Medicare UPIN
INM400033974Medicare PIN
INM400073247Medicare PIN
IN142650KMedicare PIN
IN100212020Medicaid