Provider Demographics
NPI:1609042282
Name:ROBERT A CORNETTE PH D P C
Entity Type:Organization
Organization Name:ROBERT A CORNETTE PH D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:CORNETTE
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:248-569-5268
Mailing Address - Street 1:29260 FRANKLIN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1161
Mailing Address - Country:US
Mailing Address - Phone:248-569-5268
Mailing Address - Fax:248-569-1291
Practice Address - Street 1:29260 FRANKLIN ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1182
Practice Address - Country:US
Practice Address - Phone:248-569-5268
Practice Address - Fax:248-569-1291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRC000724103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680F349690OtherBLUE CROSS
MI0F34969Medicare PIN