1861657975 NPI number — DR. MOSHE BERACHA KOVACHEVICH MD

Table of content: DR. MOSHE BERACHA KOVACHEVICH MD (NPI 1861657975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861657975 NPI number — DR. MOSHE BERACHA KOVACHEVICH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERACHA KOVACHEVICH
Provider First Name:
MOSHE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KOVACEVIC
Provider Other First Name:
MOSA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1861657975
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
175 W B ST BLDG K2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97477-4575
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-502-5750
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1919 WOODLAWN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97403-1887
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-502-5750
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X , with the licence number:  MD28403 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: MD28403 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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