1730134461 NPI number — DR. BRIAN J KORNBLATT MD

Table of content: DR. BRIAN J KORNBLATT MD (NPI 1730134461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730134461 NPI number — DR. BRIAN J KORNBLATT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KORNBLATT
Provider First Name:
BRIAN
Provider Middle Name:
J
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:
1730134461
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 EXECUTIVE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31406-3345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-355-2400
Provider Business Mailing Address Fax Number:
912-355-5324

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 EXECUTIVE CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31406-3345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-355-2400
Provider Business Practice Location Address Fax Number:
912-355-5324
Provider Enumeration Date:
05/23/2006

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: 207P00000X , with the licence number:  038029 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207P00000X , with the licence number: 20004 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000594624B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000594624Q , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000594624T , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000594624U , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000594624H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000594624F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000594624R , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000594624D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000594624S , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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