Basic Information
| Provider Information | |||||||||
| NPI: | 1144394206 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POPOVICH | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950112 | ||||||||
| Address2: | DEPT. 52387 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669653774 | ||||||||
| FaxNumber: | 7812766411 | ||||||||
| Practice Location | |||||||||
| Address1: | 913 N DIXIE AVE | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427012503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8777836257 | ||||||||
| FaxNumber: | 8595145521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 10/06/2016 | ||||||||
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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 | 207P00000X | M5446 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 03164 | KY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00650256 | 01 | TX | RAILROAD | OTHER | 188382902 | 05 | TX | MEDICAID | 8AA314 | 01 | TX | BCBS | OTHER | 8W1785 | 01 | TX | BCBS | OTHER |