Basic Information
Provider Information | |||||||||
NPI: | 1578525713 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOVAC | ||||||||
FirstName: | KIM | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS PT CHT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1115 BOULDERS PKWY | ||||||||
Address2: | SUITE 200 | ||||||||
City: | NORTH CHESTERFIELD | ||||||||
State: | VA | ||||||||
PostalCode: | 232254067 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8045605595 | ||||||||
FaxNumber: | 8045609029 | ||||||||
Practice Location | |||||||||
Address1: | 7650 E PARHAM RD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | RICHMOND | ||||||||
State: | VA | ||||||||
PostalCode: | 232944373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8042826338 | ||||||||
FaxNumber: | 8042853237 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2006 | ||||||||
LastUpdateDate: | 09/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305004075 | VA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 010200768 | 05 | VA |   | MEDICAID | 192953 | 01 | VA | BCBS (PHYSICAL THERAPY) | OTHER | 710746 | 01 |   | AETNA | OTHER | P00263215 | 01 | VA | RAILROAD MEDICARE | OTHER |