Provider Demographics
NPI:1114913050
Name:CORNNELL, TIMOTHY J (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:CORNNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 N KINGS HWY STE A
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-3055
Mailing Address - Country:US
Mailing Address - Phone:843-449-3381
Mailing Address - Fax:843-839-0275
Practice Address - Street 1:7900 N KINGS HWY STE A
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-3055
Practice Address - Country:US
Practice Address - Phone:843-449-3381
Practice Address - Fax:843-839-0275
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19597207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC195979Medicaid
SC891261395Medicare ID - Type Unspecified
SC195979Medicaid