Provider Demographics
NPI:1578597936
Name:CORNISH, ALLEN LEE III (MD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:LEE
Last Name:CORNISH
Suffix:III
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 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-4661
Mailing Address - Fax:859-258-4620
Practice Address - Street 1:1221 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2701
Practice Address - Country:US
Practice Address - Phone:859-258-4661
Practice Address - Fax:859-258-4620
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18114207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4000501OtherMEDICARE LAB GROUP
KY37903705OtherMEDICAID LAB GROUP
KY36000818OtherMEDICAID ASC GROUP
KYASC1019OtherMEDICARE ASC GROUP
GA110055332OtherRR MEDICARE PIN
GACB5773OtherRR MEDICARE GROUP
KY64181142Medicaid
C77459Medicare UPIN
KY37903705OtherMEDICAID LAB GROUP
KY64181142Medicaid