Provider Demographics
NPI:1861449720
Name:KORNELY PODIATRY, LLC
Entity Type:Organization
Organization Name:KORNELY PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:G
Authorized Official - Last Name:KORNELY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:262-335-2930
Mailing Address - Street 1:2358 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-2118
Mailing Address - Country:US
Mailing Address - Phone:262-335-2930
Mailing Address - Fax:262-335-2931
Practice Address - Street 1:2358 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-2118
Practice Address - Country:US
Practice Address - Phone:262-335-2930
Practice Address - Fax:262-335-2931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI774-025213E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43225400Medicaid
000086151Medicare ID - Type Unspecified
WI43267800Medicaid