Provider Demographics
NPI:1699946459
Name:PORT HURON NEUROLOGIC ASSOCIATES P.C.
Entity type:Organization
Organization Name:PORT HURON NEUROLOGIC ASSOCIATES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:KOVAR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:810-982-0100
Mailing Address - Street 1:3825 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-4100
Mailing Address - Country:US
Mailing Address - Phone:810-982-0100
Mailing Address - Fax:810-982-0365
Practice Address - Street 1:3825 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-4100
Practice Address - Country:US
Practice Address - Phone:810-982-0100
Practice Address - Fax:810-982-0365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010111112084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3072470-11Medicaid
MI5740293OtherBCBS
MI130009974Medicare PIN
MIF02026Medicare UPIN
MI3072470-11Medicaid