Provider Demographics
NPI:1437183381
Name:JAN R KORNILOW, M.D., LLC
Entity Type:Organization
Organization Name:JAN R KORNILOW, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:KORNILOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-969-1950
Mailing Address - Street 1:PO BOX 2347
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-2347
Mailing Address - Country:US
Mailing Address - Phone:260-969-1950
Mailing Address - Fax:260-918-2137
Practice Address - Street 1:2901 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-4307
Practice Address - Country:US
Practice Address - Phone:765-751-5010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200814160AMedicaid
INDP1120OtherRAILROAD MEDICARE
INDP1120OtherRAILROAD MEDICARE