Basic Information
| Provider Information | |||||||||
| NPI: | 1003873423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORNETT | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026292500 | ||||||||
| FaxNumber: | 5026293165 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026292500 | ||||||||
| FaxNumber: | 5026293165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 28989 | KY | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1757375 | 01 | KY | CIGNA PROVIDER NUMBER | OTHER | 920005753 | 01 | KY | RAILROAD MEDICARE | OTHER | 000000178939 | 01 | KY | ANTHEM PROVIDER NUMB | OTHER | 1118125 | 01 | KY | PASSPORTPROVIDER NUMB | OTHER | 64289895 | 05 | KY | MEDICAID | 000020583J | 01 | KY | HUMANA PROVIDER NUMB | OTHER | 200035990 | 05 | IN | MEDICAID | 5941087 | 01 | KY | AETNA PROVIDER NUMB | OTHER |