Basic Information
| Provider Information | |||||||||
| NPI: | 1902819162 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOVAN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4660 S HAGADORN RD | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488235353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178846100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4660 S HAGADORN RD STE 420 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488235353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178846100 | ||||||||
| FaxNumber: | 5178846233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 04/13/2011 | ||||||||
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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 | 5101010030 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 5101010030 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1902819162 | 05 | MI | MEDICAID | 3194525 | 05 | MI | MEDICAID |