1669570198 NPI number — MRS. CYNTHIA ANN CORNELL OTR L

Table of content: MRS. CYNTHIA ANN CORNELL OTR L (NPI 1669570198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669570198 NPI number — MRS. CYNTHIA ANN CORNELL OTR L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORNELL
Provider First Name:
CYNTHIA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FLOCK
Provider Other First Name:
CYNTHIA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1669570198
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 CLIFTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-756-5375
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
270 STERKEL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44907-2207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-756-1133
Provider Business Practice Location Address Fax Number:
419-756-6544
Provider Enumeration Date:
09/20/2006

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: 225X00000X , with the licence number:  OT 02865 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3407897499238 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000125368 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".




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