Basic Information
| Provider Information | |||||||||
| NPI: | 1285843896 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORNELIUS | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | PHILIP | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 370 | ||||||||
| Address2: | |||||||||
| City: | FORTSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 318080370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 7064943008 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PHYSICIANS WAY | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370908102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155476700 | ||||||||
| FaxNumber: | 6155476707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 08/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 44463 | TN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | 44463 | TN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1513462 | 05 | TN | MEDICAID |