Provider Demographics
NPI:1689621898
Name:EVANKOVICH, MICHAEL RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RICHARD
Last Name:EVANKOVICH
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 1:311 W 24TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-2668
Mailing Address - Country:US
Mailing Address - Phone:814-452-4214
Mailing Address - Fax:814-459-7823
Practice Address - Street 1:311 W 24TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-2665
Practice Address - Country:US
Practice Address - Phone:814-452-4214
Practice Address - Fax:814-459-7823
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD060400L208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02079629OtherNY MEDICAL ASSISTANCE
PA182151OtherUNISON
PA212543OtherUPMC
PA261978OtherBLUE SHIELD
PAP00324768OtherRR MEDICARE
OH2662659OtherOH MEDICAL ASSISTANCE
PA1278964OtherAETNA
NY00025198402OtherUNIVERA
PA1041777OtherGATEWAY
PA0017973700003Medicaid
PA182151OtherUNISON
PA0017973700003Medicaid