Basic Information
| Provider Information | |||||||||
| NPI: | 1184200610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOVACEVIC | ||||||||
| FirstName: | STEFAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8327 N NEWLAND AVE | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607142641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477495395 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 355 RIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602023328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473164000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2021 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.