Provider Demographics
NPI:1598771339
Name:KOVACEK PETERSON MANAGEMENT LLC
Entity Type:Organization
Organization Name:KOVACEK PETERSON MANAGEMENT LLC
Other - Org Name:LONGTERM CARE REHAB MANGEMENT SERVICE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:KOVACEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-774-5774
Mailing Address - Street 1:12 KINGSLEY CT
Mailing Address - Street 2:
Mailing Address - City:FRANKENMUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48734-1270
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 KINGSLEY CT
Practice Address - Street 2:
Practice Address - City:FRANKENMUTH
Practice Address - State:MI
Practice Address - Zip Code:48734-1270
Practice Address - Country:US
Practice Address - Phone:989-793-2856
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009515225100000X
MI5201000937225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDD5657OtherMEDICARE RAILROAD
MI650G312140OtherBLUE CROSS BLUE SHIELD MI
MI650G312140OtherBLUE CROSS BLUE SHIELD MI
MI0N72710Medicare PIN