Provider Demographics
NPI:1689281610
Name:CORNELL MEDICAL LLC
Entity Type:Organization
Organization Name:CORNELL MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:CORNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-883-7993
Mailing Address - Street 1:PO BOX 80556
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-0006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 UNICORN PARK DR STE 302
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-3342
Practice Address - Country:US
Practice Address - Phone:781-756-2308
Practice Address - Fax:781-756-4798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA23738Medicaid