Basic Information
| Provider Information | |||||||||
| NPI: | 1538249990 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORNELIUS | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | W225N16711 CEDAR PARK CT | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530379222 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 W PARADISE DR | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530959795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623343451 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 07/18/2012 | ||||||||
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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 | 207Q00000X | 25227 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1004 | 01 | INTERNAL ID-MOTOR VEHICLE ID | OTHER |