Healthcare Provider Details

I. General information

NPI: 1558449124
Provider Name (Legal Business Name): MICHAEL STEPHEN KORNISH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 02/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 6TH AVE SW
RONAN MT
59864-2634
US

IV. Provider business mailing address

111 APPLE HOUSE LN
MISSOULA MT
59802-3324
US

V. Phone/Fax

Practice location:
  • Phone: 406-676-4441
  • Fax: 406-676-0835
Mailing address:
  • Phone: 406-493-6318
  • Fax: 406-493-6318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number7286
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7286
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: