Basic Information
| Provider Information | |||||||||
| NPI: | 1538145263 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUNOVICH | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 449 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457500449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403744500 | ||||||||
| FaxNumber: | 7403745887 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 WAYNE ST STE 112 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457503309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403734288 | ||||||||
| FaxNumber: | 7403734254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 34006878 | OH | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 000000696929 | 01 | OH | ANTHEM | OTHER | 2080215 | 05 | OH | MEDICAID | P00327899 | 01 | OH | RRMCR | OTHER | 000000379607 | 01 | OH | ANTHEM | OTHER | 0010530000 | 05 | WV | MEDICAID |