Provider Demographics
NPI:1629250097
Name:KORNEGOR, RUSSELL D
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:D
Last Name:KORNEGOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHHMEL.11296332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000283155OtherANTHEM
OH2324701Medicaid
OH2324701Medicaid