MEDICARE: MR. ELANGHOVAN V KOVOOR RPT

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	5501004961	MI

General Provider Information

NPI Number	:	1871705822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ELANGHOVAN V KOVOOR RPT

Provider Business Mailing Address
First Line	:	6481 RUTLEDGE PARK DR
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-2458
Country	:	US
Telephone Number	:	989-865-0406
Fax Number	:	989-865-0406

Provider Business Practice Location Address
First Line	:	6481 RUTLEDGE PARK DR
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-2458
Country	:	US
Telephone Number	:	989-865-0406
Fax Number	:	989-865-0406

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

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	05/24/2011

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