MEDICARE: KOVANDA PLASTIC SURGERY, PLLC

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	2086S0122X	Plastic and Reconstructive Surgery Physician	41657	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1861501082	OTHER		NPI INDIVIDUAL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447484159
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOVANDA PLASTIC SURGERY, PLLC

Provider Business Mailing Address
First Line	:	9325 UPLAND LN N
Second Line	:	SUITE 205
City	:	MAPLE GROVE
State	:	MN
Zip	:	55369-4200
Country	:	US
Telephone Number	:	763-416-0676
Fax Number	:	763-416-0476

Provider Business Practice Location Address
First Line	:	4999 FRANCE AVE S STE 210
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55410-2168
Country	:	US
Telephone Number	:	612-335-9032
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	CHRISTOPHER JOHN KOVANDA
Credential	:	M.D.
Telephone Number	:	763-416-0676

Provider Enumeration Date	:	05/08/2009
Last Update Date	:	12/10/2019

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