MEDICARE: ELLIOT HAROLD KORNBERG M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	ME0025763	FL

General Provider Information

NPI Number	:	1467459883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLIOT HAROLD KORNBERG M.D.

Provider Business Mailing Address
First Line	:	650 N ATLANTIC AVE
Second Line	:	PENTHOUSE 5
City	:	COCOA BEACH
State	:	FL
Zip	:	32931-3119
Country	:	US
Telephone Number	:	321-783-7079
Fax Number	:	321-783-5228

Provider Business Practice Location Address
First Line	:	1980 N ATLANTIC AVE
Second Line	:	SUITE 416
City	:	COCOA BEACH
State	:	FL
Zip	:	32931-5213
Country	:	US
Telephone Number	:	321-783-7079
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	07/08/2007

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