Basic Information
Provider Information | |||||||||
NPI: | 1023007259 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CORNWELL | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 460 TOTTEN POND RD | ||||||||
Address2: | C/O MZI | ||||||||
City: | WALTHAM | ||||||||
State: | MA | ||||||||
PostalCode: | 024511991 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7818909933 | ||||||||
FaxNumber: | 7818909930 | ||||||||
Practice Location | |||||||||
Address1: | 88 WASHINGTON ST | ||||||||
Address2: | ATTN EMERGENCY DEPT | ||||||||
City: | TAUNTON | ||||||||
State: | MA | ||||||||
PostalCode: | 027802465 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5088287108 | ||||||||
FaxNumber: | 5088287158 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2005 | ||||||||
LastUpdateDate: | 02/22/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 70426 | MA | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | J10558 | 01 | MA | BCBS | OTHER | 410296 | 01 | MA | TUFTS | OTHER | 437057 | 01 | MA | HPHC | OTHER | 0121657 | 05 | MA |   | MEDICAID |