Basic Information
| Provider Information | |||||||||
| NPI: | 1679562722 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KORNBLUM | ||||||||
| FirstName: | MARTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43800 GARFIELD RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008480202 | ||||||||
| FaxNumber: | 5862266949 | ||||||||
| Practice Location | |||||||||
| Address1: | 11885 E 12 MILE RD | ||||||||
| Address2: | 200B | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865827070 | ||||||||
| FaxNumber: | 5865827066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207XS0117X | 4301063387 | MI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | 4209319 | 05 | MI | MEDICAID |