1063689727 NPI number — RACHEL I KORNIK M.D.

Table of content: RACHEL I KORNIK M.D. (NPI 1063689727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063689727 NPI number — RACHEL I KORNIK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KORNIK
Provider First Name:
RACHEL
Provider Middle Name:
I
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1063689727
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1234
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12201-1234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-582-8239
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
53 FAIRFAX RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT ALBANS
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05478-4405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-582-4900
Provider Business Practice Location Address Fax Number:
802-782-8239
Provider Enumeration Date:
05/13/2008

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: 207N00000X , with the licence number:  042.0015116 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , with the licence number: 54704-20 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1063689727 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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