MEDICARE: MR. PETER RAY KOVACEK PT

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	225100000X	Physical Therapist	5501001577	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	650H258050	OTHER	MI	BCBSM
2	11549713	OTHER	MI	CAQH

General Provider Information

NPI Number	:	1700850252
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PETER RAY KOVACEK PT

Provider Business Mailing Address
First Line	:	20225 DANBURY LN
Second Line	:
City	:	HARPER WOODS
State	:	MI
Zip	:	48225-1156
Country	:	US
Telephone Number	:	313-492-4293
Fax Number	:	313-884-8510

Provider Business Practice Location Address
First Line	:	19701 VERNIER RD
Second Line	:
City	:	HARPER WOODS
State	:	MI
Zip	:	48225-1467
Country	:	US
Telephone Number	:	313-884-8920
Fax Number	:	313-884-8510

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

Provider Enumeration Date	:	02/13/2006
Last Update Date	:	04/24/2008

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