Provider Demographics
NPI:1558449124
Name:KORNISH, MICHAEL STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:KORNISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:111 APPLE HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-3324
Mailing Address - Country:US
Mailing Address - Phone:406-493-6318
Mailing Address - Fax:406-493-6318
Practice Address - Street 1:107 6TH AVE SW
Practice Address - Street 2:
Practice Address - City:RONAN
Practice Address - State:MT
Practice Address - Zip Code:59864-2634
Practice Address - Country:US
Practice Address - Phone:406-676-4441
Practice Address - Fax:406-676-0835
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT7286207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT43367Medicaid
MTF50305Medicare UPIN