Healthcare Provider Details

I. General information

NPI: 1740630474
Provider Name (Legal Business Name): JOSEPH KOVACICH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-933-1340
  • Fax:
Mailing address:
  • Phone: 410-933-1340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberH91245
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: