Basic Information
| Provider Information | |||||||||
| NPI: | 1205119799 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RASTISLAV KUCINSKY MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5109 | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976010119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418821540 | ||||||||
| FaxNumber: | 5418822583 | ||||||||
| Practice Location | |||||||||
| Address1: | 2614 CLOVER ST | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976011132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418846233 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2011 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | KUCINSKY | ||||||||
| AuthorizedOfficialFirstName: | RASTISLAV | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5418846233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | MD28454 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | MD28454 | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 026194 | 05 | OR | MEDICAID | P00641241 | 01 | OR | RAILROAD MEDICARE | OTHER |