Basic Information
| Provider Information | |||||||||
| NPI: | 1073587507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOVACHEVICH | ||||||||
| FirstName: | ROBERT | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15900 W 101ST AVE | ||||||||
| Address2: | MARCOTTE MEDICAL GROUP, SC | ||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193656333 | ||||||||
| FaxNumber: | 2193656333 | ||||||||
| Practice Location | |||||||||
| Address1: | 15900 W 101ST AVE | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193656333 | ||||||||
| FaxNumber: | 2193658291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 04/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02002505A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200400350 | 05 | IN | MEDICAID | 000000513385 | 01 | IN | ANTHEM | OTHER | DE6640 | 01 | IN | RAILROAD | OTHER | P00462444 | 01 | IN | RAILROAD | OTHER |