Basic Information
| Provider Information | |||||||||
| NPI: | 1437183381 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JAN R KORNILOW, M.D., LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2347 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462062347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609691950 | ||||||||
| FaxNumber: | 2609182137 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 W JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473044307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657515010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | KORNILOW | ||||||||
| AuthorizedOfficialFirstName: | JAN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2609691950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200814160A | 05 | IN | MEDICAID | DP1120 | 01 | IN | RAILROAD MEDICARE | OTHER |