MEDICARE: KURT KRIZTOFER KOVALOVICH DPM

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	213EP1101X	Primary Podiatric Medicine Podiatrist	SC003328R	PA

General Provider Information

NPI Number	:	1316945496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KURT KRIZTOFER KOVALOVICH DPM

Provider Business Mailing Address
First Line	:	PO BOX 167
Second Line	:	185 S TULPEHOCKEN ST
City	:	PINE GROVE
State	:	PA
Zip	:	17963-0167
Country	:	US
Telephone Number	:	570-345-6301
Fax Number	:	570-345-2626

Provider Business Practice Location Address
First Line	:	185 S TULPEHOCKEN ST
Second Line	:
City	:	PINE GROVE
State	:	PA
Zip	:	17963-1029
Country	:	US
Telephone Number	:	570-345-6301
Fax Number	:	570-345-2626

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	11/30/2009

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