Provider Demographics
NPI:1528153780
Name:KORECKIJ, THEODORE NMI (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:NMI
Last Name:KORECKIJ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 W 10TH ST
Mailing Address - Street 2:ATTN; EXECUTIVE DIRECTOR OF PHYSICIAN CLINICS
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2905
Mailing Address - Country:US
Mailing Address - Phone:573-364-9000
Mailing Address - Fax:573-426-2108
Practice Address - Street 1:1050 W 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2905
Practice Address - Country:US
Practice Address - Phone:573-364-5633
Practice Address - Fax:573-426-5314
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94881207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201445004Medicaid
21397OtherBLUE CROSS
200012334OtherRAILROAD MEDICARE
200012334OtherRAILROAD MEDICARE
MO000004990Medicare ID - Type Unspecified