Provider Demographics
NPI:1700850252
Name:KOVACEK, PETER RAY (PT)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:RAY
Last Name:KOVACEK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20225 DANBURY LN
Mailing Address - Street 2:
Mailing Address - City:HARPER WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48225-1156
Mailing Address - Country:US
Mailing Address - Phone:313-492-4293
Mailing Address - Fax:313-884-8510
Practice Address - Street 1:19701 VERNIER RD
Practice Address - Street 2:
Practice Address - City:HARPER WOODS
Practice Address - State:MI
Practice Address - Zip Code:48225-1467
Practice Address - Country:US
Practice Address - Phone:313-884-8920
Practice Address - Fax:313-884-8510
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501001577225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650H258050OtherBCBSM
MI11549713OtherCAQH
MI0N64560001Medicare PIN
MI650H258050OtherBCBSM
MI0N64560Medicare PIN
MIP25560002Medicare PIN
MIN71890001Medicare PIN