Provider Demographics
NPI:1700833563
Name:MEDICAL REHABILITATION GROUP PC
Entity Type:Organization
Organization Name:MEDICAL REHABILITATION GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:KOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-606-7181
Mailing Address - Street 1:4632 GENESYS PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8067
Mailing Address - Country:US
Mailing Address - Phone:810-606-7181
Mailing Address - Fax:810-606-5803
Practice Address - Street 1:4632 GENESYS PKWY
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8067
Practice Address - Country:US
Practice Address - Phone:810-606-7181
Practice Address - Fax:810-606-5803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055356208100000X
MI5101011645208100000X
MI4301072856208100000X
MI5101011977208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4510933Medicaid
MI3477280Medicaid
MI2984537Medicaid
MI4614885Medicaid
MIF27009Medicare UPIN
MI3477280Medicaid
MIA16046Medicare UPIN
MI4614885Medicaid
MI4510933Medicaid