Basic Information
| Provider Information | |||||||||
| NPI: | 1144215682 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOVALCHICK | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 W KING ST | ||||||||
| Address2: | |||||||||
| City: | LITTLESTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173401446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7173599214 | ||||||||
| FaxNumber: | 7173598120 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 W KING ST | ||||||||
| Address2: | |||||||||
| City: | LITTLESTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173401446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7173599214 | ||||||||
| FaxNumber: | 7173598120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 05/27/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS009495L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001675582 | 05 | PA | MEDICAID |