MEDICARE: PORT HURON NEUROLOGIC ASSOCIATES P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	5101011111	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	5740293	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1699946459
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORT HURON NEUROLOGIC ASSOCIATES P.C.

Provider Business Mailing Address
First Line	:	3825 24TH AVE
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-4100
Country	:	US
Telephone Number	:	810-982-0100
Fax Number	:	810-982-0365

Provider Business Practice Location Address
First Line	:	3825 24TH AVE
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-4100
Country	:	US
Telephone Number	:	810-982-0100
Fax Number	:	810-982-0365

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD RALPH KOVAR
Credential	:	D.O.
Telephone Number	:	810-982-0100

Provider Enumeration Date	:	03/19/2008
Last Update Date	:	10/29/2019

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