1619966520 NPI number — DR. BRIAN P CORNNELL MD

Table of content: DR. BRIAN P CORNNELL MD (NPI 1619966520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619966520 NPI number — DR. BRIAN P CORNNELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORNNELL
Provider First Name:
BRIAN
Provider Middle Name:
P
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619966520
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14609
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33766-4609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-793-9300
Provider Business Mailing Address Fax Number:
727-712-4688

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 PASADENA AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH PASADENA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33707-3717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-381-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  ME0042908 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 043847200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300017097 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 02090 . This is a "BLUE CROSS OF FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 104377900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com