Provider Demographics
NPI:1346276003
Name:CORNELL, EARL G (MD)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:G
Last Name:CORNELL
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 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803
Mailing Address - Country:US
Mailing Address - Phone:620-421-0600
Mailing Address - Fax:620-421-8476
Practice Address - Street 1:1509 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:KS
Practice Address - Zip Code:67357
Practice Address - Country:US
Practice Address - Phone:620-421-0600
Practice Address - Fax:620-421-8476
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0419978207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110838OtherKS BCBS
B69190Medicare UPIN
KS102463Medicare PIN