Provider Demographics
NPI:1285843896
Name:CORNELIUS, JONATHAN PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PHILIP
Last Name:CORNELIUS
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:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:100 PHYSICIANS WAY
Practice Address - Street 2:SUITE 110
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37090-8102
Practice Address - Country:US
Practice Address - Phone:615-547-6700
Practice Address - Fax:615-547-6707
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44463207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1513462Medicaid
TN3041688Medicare PIN