Provider Demographics
NPI:1376524892
Name:KORNHAUS, R KIM (MD)
Entity Type:Individual
Prefix:MR
First Name:R
Middle Name:KIM
Last Name:KORNHAUS
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 366
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44610-0366
Mailing Address - Country:US
Mailing Address - Phone:330-893-2341
Mailing Address - Fax:330-893-3027
Practice Address - Street 1:4907A DALBEY LANE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:OH
Practice Address - Zip Code:44610
Practice Address - Country:US
Practice Address - Phone:330-893-2341
Practice Address - Fax:330-893-3027
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35066090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0184250Medicaid
OH0786062Medicare PIN
OH0786063Medicare PIN
OH0786061Medicare PIN
OH0786064Medicare PIN
OH0184250Medicaid