1669505590 NPI number — DR. PETER JOHN CORNISH PH.D.

Table of content: DR. PETER JOHN CORNISH PH.D. (NPI 1669505590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669505590 NPI number — DR. PETER JOHN CORNISH PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORNISH
Provider First Name:
PETER
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.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:
1669505590
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1367 VALENCIA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NISKAYUNA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12309-5331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-382-5891
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2310 NOTT ST E
Provider Second Line Business Practice Location Address:
C/O ASSOC. IN MENTAL HEALTH AND NEUROPSYCHOLOGY
Provider Business Practice Location Address City Name:
NISKAYUNA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12309-4303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-505-1961
Provider Business Practice Location Address Fax Number:
518-694-7348
Provider Enumeration Date:
03/13/2007

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: 103TC0700X , with the licence number:  011941 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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