1003873423 NPI number — DR. MARK S CORNETT M.D.

Table of content: DR. MARK S CORNETT M.D. (NPI 1003873423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003873423 NPI number — DR. MARK S CORNETT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORNETT
Provider First Name:
MARK
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1003873423
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776347
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6347
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-588-9490
Provider Business Mailing Address Fax Number:
502-272-5116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4123 DUTCHMANS LN STE G2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-899-6601
Provider Business Practice Location Address Fax Number:
502-899-6644
Provider Enumeration Date:
04/28/2006

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: 2085R0001X , with the licence number:  28989 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1757375 . This is a "CIGNA PROVIDER NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1118125 . This is a "PASSPORTPROVIDER NUMB" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64289895 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000020583J . This is a "HUMANA PROVIDER NUMB" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 5941087 . This is a "AETNA PROVIDER NUMB" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 200035990 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 920005753 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000178939 . This is a "ANTHEM PROVIDER NUMB" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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