Provider Demographics
NPI:1972875367
Name:RUSSELL S GORNICHEC MD PC
Entity Type:Organization
Organization Name:RUSSELL S GORNICHEC MD PC
Other - Org Name:RUSSELL S GORNICHEC MD PA
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:GORNICHEC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-781-0772
Mailing Address - Street 1:115 BIG DUKE TRL
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-2515
Mailing Address - Country:US
Mailing Address - Phone:501-778-7300
Mailing Address - Fax:501-778-7301
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:71901-3931
Practice Address - Country:US
Practice Address - Phone:501-781-0772
Practice Address - Fax:501-781-4000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE7873208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========Medicare PIN