Provider Demographics
NPI:1225629652
Name:GAZENKO SURGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:GAZENKO SURGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAZENKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-806-6770
Mailing Address - Street 1:1010 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-3417
Mailing Address - Country:US
Mailing Address - Phone:479-705-2310
Mailing Address - Fax:479-705-2300
Practice Address - Street 1:1010 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-3417
Practice Address - Country:US
Practice Address - Phone:479-705-2310
Practice Address - Fax:479-705-2300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR210971001Medicaid