Provider Demographics
NPI:1114140761
Name:RUSSELL KORNEGOR MEDICAL EQUIPMENT LTD
Entity Type:Organization
Organization Name:RUSSELL KORNEGOR MEDICAL EQUIPMENT LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:KORNEGOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-678-2168
Mailing Address - Street 1:703 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:OH
Mailing Address - Zip Code:45828-9780
Mailing Address - Country:US
Mailing Address - Phone:419-678-2168
Mailing Address - Fax:419-678-8893
Practice Address - Street 1:703 N 2ND ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:OH
Practice Address - Zip Code:45828-9780
Practice Address - Country:US
Practice Address - Phone:419-678-2168
Practice Address - Fax:419-678-8893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2324701Medicaid
OH4483250001Medicare NSC