Healthcare Provider Details

I. General information

NPI: 1821178740
Provider Name (Legal Business Name): THOMAS PAUL CORNWALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 08/02/2020
Certification Date: 08/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3019 FALSTAFF RD
RALEIGH NC
27610-1812
US

IV. Provider business mailing address

760 BEAR TREE CRK
CHAPEL HILL NC
27517-7662
US

V. Phone/Fax

Practice location:
  • Phone: 919-250-7000
  • Fax:
Mailing address:
  • Phone: 919-247-7992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number18400
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number18400
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: