Healthcare Provider Details

I. General information

NPI: 1063689727
Provider Name (Legal Business Name): RACHEL I KORNIK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 FAIRFAX RD
SAINT ALBANS VT
05478-4405
US

IV. Provider business mailing address

PO BOX 1234
ALBANY NY
12201-1234
US

V. Phone/Fax

Practice location:
  • Phone: 802-582-4900
  • Fax: 802-782-8239
Mailing address:
  • Phone: 802-582-8239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number042.0015116
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number54704-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: