Healthcare Provider Details

I. General information

NPI: 1023935962
Provider Name (Legal Business Name): RYAN KOVARIK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3417 ANDERSON HEALTHCARE DR STE 103
EDWARDSVILLE IL
62025-7758
US

IV. Provider business mailing address

3550 COLLEGE AVE
ALTON IL
62002-5008
US

V. Phone/Fax

Practice location:
  • Phone: 618-635-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160008252
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: