Provider Demographics
NPI:1437121860
Name:GORNICHEC, RUSSELL S (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:S
Last Name:GORNICHEC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-3931
Mailing Address - Country:US
Mailing Address - Phone:501-781-0772
Mailing Address - Fax:501-781-4000
Practice Address - Street 1:501 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901
Practice Address - Country:US
Practice Address - Phone:501-781-0772
Practice Address - Fax:501-781-4000
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2021-01-06
Deactivation Date:2019-02-19
Deactivation Code:
Reactivation Date:2019-06-27
Provider Licenses
StateLicense IDTaxonomies
ARE7873208600000X
OK21488208600000X
IN01077212A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN7008146OtherAETNA
IN1021531OtherANTHEM
AR201233001Medicaid
KY50113964OtherKY PASSPORT
OKP00013588OtherRAILROAD MEDICARE
OK100827130BMedicaid
KY7100430200Medicaid
OKP00013588OtherRAILROAD MEDICARE