Provider Demographics
NPI: | 1790858637 |
---|---|
Name: | CORNELIUS, CHRIS ROBERT (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | CHRIS |
Middle Name: | ROBERT |
Last Name: | CORNELIUS |
Suffix: | |
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: | 19 SPELLMAN TER |
Mailing Address - Street 2: | |
Mailing Address - City: | RUTLAND |
Mailing Address - State: | VT |
Mailing Address - Zip Code: | 05701-4123 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 802-775-1800 |
Mailing Address - Fax: | 802-775-1820 |
Practice Address - Street 1: | 215 STRATTON RD |
Practice Address - Street 2: | |
Practice Address - City: | RUTLAND |
Practice Address - State: | VT |
Practice Address - Zip Code: | 05701-4621 |
Practice Address - Country: | US |
Practice Address - Phone: | 802-773-3386 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-11-16 |
Last Update Date: | 2023-04-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | ME76538 | 207Q00000X |
VT | 042-0010037 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VT | 08497 | Other | MVP |
VT | 1009665 | Medicaid | |
VT | P00168543 | Other | MEDICARE RAILROAD |
VT | 3203553 | Other | CIGNA |
VT | 59378 | Other | BCBS |
VT | 08497 | Other | MVP |
VT | P00168543 | Other | MEDICARE RAILROAD |