Basic Information
| Provider Information | |||||||||
| NPI: | 1528153780 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KORECKIJ | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | NMI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 W 10TH ST | ||||||||
| Address2: | ATTN; EXECUTIVE DIRECTOR OF PHYSICIAN CLINICS | ||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654012905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733649000 | ||||||||
| FaxNumber: | 5734262108 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654012905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733645633 | ||||||||
| FaxNumber: | 5734265314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 04/11/2018 | ||||||||
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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 | 207X00000X | ME94881 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 201445004 | 05 | MO | MEDICAID | 21397 | 01 | BLUE CROSS | OTHER | 200012334 | 01 | RAILROAD MEDICARE | OTHER |