MEDICARE: GENNADY G MIROSHNICHENKO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	P4595	TX
2	207VX0201X	Gynecologic Oncology Physician	P4595	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	8DM684	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1164784450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENNADY G MIROSHNICHENKO MD

Provider Business Mailing Address
First Line	:	PO BOX 732973
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75373-2973
Country	:	US
Telephone Number	:	817-702-8450
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 S MAIN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4804
Country	:	US
Telephone Number	:	817-702-6500
Fax Number	:	817-702-6561

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2012
Last Update Date	:	02/01/2021

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