Provider Demographics
NPI:1275684060
Name:CORNELL ABRAXAS GROUP INC.
Entity Type:Organization
Organization Name:CORNELL ABRAXAS GROUP INC.
Other - Org Name:CORNELL ABRAXAS PSRU
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONSULTING PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BARON
Authorized Official - Middle Name:
Authorized Official - Last Name:DENNISTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:814-459-0618
Mailing Address - Street 1:429 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1215
Mailing Address - Country:US
Mailing Address - Phone:814-459-0618
Mailing Address - Fax:814-459-0682
Practice Address - Street 1:429 W 6TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1215
Practice Address - Country:US
Practice Address - Phone:814-459-0618
Practice Address - Fax:814-459-0682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1007472500003323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007472500001Medicaid