Healthcare Provider Details

I. General information

NPI: 1992739312
Provider Name (Legal Business Name): JASON THEODORE KORECKIJ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S KEENE ST
COLUMBIA MO
65201-7199
US

IV. Provider business mailing address

1 S KEENE ST
COLUMBIA MO
65201-7199
US

V. Phone/Fax

Practice location:
  • Phone: 573-443-2402
  • Fax: 573-443-0574
Mailing address:
  • Phone: 573-443-2402
  • Fax: 573-443-0574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number2009007659
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: