Healthcare Provider Details

I. General information

NPI: 1861220972
Provider Name (Legal Business Name): JOHN CORNELIUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MEDICAL PARK RD STE 402
COLUMBIA SC
29203-6839
US

IV. Provider business mailing address

2 MEDICAL PARK RD STE 402
COLUMBIA SC
29203-6839
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-4153
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberLL96896
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: