Provider Demographics
NPI:1508904715
Name:MARC J KORNFIELD MD PC
Entity Type:Organization
Organization Name:MARC J KORNFIELD MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:E
Authorized Official - Last Name:DENIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-425-1170
Mailing Address - Street 1:1335 CANTON RD STE C
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6053
Mailing Address - Country:US
Mailing Address - Phone:770-425-1170
Mailing Address - Fax:770-425-1137
Practice Address - Street 1:1335 CANTON RD STE C
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-6053
Practice Address - Country:US
Practice Address - Phone:770-425-1170
Practice Address - Fax:770-425-1137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA25BBFQSMedicare UPIN