Provider Demographics
NPI:1063538809
Name:MICHAEL BOVA M D S C
Entity type:Organization
Organization Name:MICHAEL BOVA M D S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:BOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-726-9346
Mailing Address - Street 1:2524 FARRAGUT DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-8400
Mailing Address - Country:US
Mailing Address - Phone:217-726-9346
Mailing Address - Fax:
Practice Address - Street 1:2524 FARRAGUT DR
Practice Address - Street 2:SUITE C
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-8400
Practice Address - Country:US
Practice Address - Phone:217-726-9346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36075342207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL088405OtherHEALTH ALLIANCE
IL166621OtherHEALTHLINK NETWORK
IL36075342Medicaid
IL08432082OtherBLUECROSS BLUESHIELD
ILDA5603OtherRAILROAD MEDICARE
3003OtherNEIC SITE ID,NSF BAO-7
3003OtherNEIC SITE ID,NSF BAO-7
IL208149Medicare PIN