Basic Information
| Provider Information | |||||||||
| NPI: | 1164498275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOVACEVICH | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30633 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441300633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408790081 | ||||||||
| FaxNumber: | 4408790084 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 5TH ST NE | ||||||||
| Address2: | |||||||||
| City: | BARBERTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442033332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307451611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207V00000X | 35-072171 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 000000311275 | 01 | OH | ANTHEM | OTHER | 2127353 | 05 | OH | MEDICAID |