Healthcare Provider Details

I. General information

NPI: 1548250830
Provider Name (Legal Business Name): JAMES ROY CORNWELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 R T STANLEY SR PLACE
LYONS GA
30436-5623
US

IV. Provider business mailing address

PO BOX 407
VIDALIA GA
30475-0407
US

V. Phone/Fax

Practice location:
  • Phone: 912-526-9355
  • Fax: 912-526-8622
Mailing address:
  • Phone: 912-526-9355
  • Fax: 912-526-8622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2016-01953
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39184
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number050608
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: