Provider Demographics
NPI:1861489510
Name:BOVA, MICHAEL P (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:BOVA
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 1:2524 FARRAGUT DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-8400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2524 FARRAGUT DR
Practice Address - Street 2:SUITE C
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-8400
Practice Address - Country:US
Practice Address - Phone:217-726-9346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00063271OtherRAILROAD MEDICARE
IL088405OtherHEALTH ALLIANCE
IL166621OtherHEALTHLINK NETWORK ID
IL3003OtherNEIC SITE ID,NSF BAO-7
IL08432082OtherBLUE CROSS BLUE SHIELD
IL3003OtherNEIC SITE ID,NSF BAO-7
ILE20960Medicare UPIN