Provider Demographics
NPI:1386679082
Name:CORNWELL, THOMAS A (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:CORNWELL
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 1:1800 N MAIN ST
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3112
Mailing Address - Country:US
Mailing Address - Phone:630-614-4960
Mailing Address - Fax:630-682-3727
Practice Address - Street 1:1800 N MAIN ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3112
Practice Address - Country:US
Practice Address - Phone:630-614-4960
Practice Address - Fax:630-682-3727
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075646207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036075646Medicaid
ILL66622OtherMEDICARE PTAN (INDIVIDUAL)
ILP00996567OtherRR MEDICARE PTAN (INDIVIDUAL)
IL080138424Medicare PIN
ILL66622OtherMEDICARE PTAN (INDIVIDUAL)
IL036075646Medicaid