Basic Information
| Provider Information | |||||||||
| NPI: | 1174596761 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORNETTA | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 414230 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022414230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038939784 | ||||||||
| FaxNumber: | 6038938886 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 HERRICK ST | ||||||||
| Address2: | BEVERLY HOSPITAL | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019151776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789223000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 12/11/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 34141 | MA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 6167942 | 05 | MA | MEDICAID | D08052 | 01 | MA | BCBS MA | OTHER | 710537 | 01 | MA | TUFTS HEALTH PLAN | OTHER | DM0438 | 01 | MA | HARVARD PILGRIM | OTHER | 220020523 | 01 | MA | RAILROAD MEDICARE | OTHER |