Healthcare Provider Details

I. General information

NPI: 1831164524
Provider Name (Legal Business Name): JEFFREY JOHN KOVACIC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 TIMMS RD NE
CALHOUN GA
30701-7016
US

IV. Provider business mailing address

PO BOX 12938 C/O CLINIC MANAGEMENT
CALHOUN GA
30703-7066
US

V. Phone/Fax

Practice location:
  • Phone: 706-602-3100
  • Fax: 706-602-3101
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number053836
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: