MEDICARE: CHARLES RUSSELL KOVALESKI MD

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	207N00000X	Dermatology Physician	ME36420	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	99500	OTHER	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811972391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES RUSSELL KOVALESKI MD

Provider Business Mailing Address
First Line	:	1900 HARRISON AVE
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4542
Country	:	US
Telephone Number	:	850-769-1668
Fax Number	:	850-785-2123

Provider Business Practice Location Address
First Line	:	1900 HARRISON AVE
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4542
Country	:	US
Telephone Number	:	850-769-1668
Fax Number	:	850-785-2123

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

Provider Enumeration Date	:	12/07/2005
Last Update Date	:	05/28/2025

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