Provider Demographics
NPI:1982634754
Name:CORNWELL, KEVIN SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:SCOTT
Last Name:CORNWELL
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 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:111 W STONE DR STE 100
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-6027
Practice Address - Country:US
Practice Address - Phone:423-247-5197
Practice Address - Fax:423-247-5254
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD40735207R00000X
NC2020-00015207RC0200X, 207RP1001X
TN40735207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00855262OtherMEDICARE RR
PENDINGMedicare UPIN
TNP00855262OtherMEDICARE RR
TN103I292928Medicare PIN
TN103I297431Medicare PIN