Provider Demographics
NPI:1306896170
Name:KORNBLUM, JEFFREY A (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:KORNBLUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 6002
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61803-6002
Mailing Address - Country:US
Mailing Address - Phone:217-326-8300
Mailing Address - Fax:870-933-8575
Practice Address - Street 1:602 W. UNIVERSITY AVENUE
Practice Address - Street 2:NEUROSURGERY
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801
Practice Address - Country:US
Practice Address - Phone:217-383-3507
Practice Address - Fax:217-383-3171
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2806207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR142431001Medicaid
IL6447860011Medicare NSC
AR142431001Medicaid
A75298Medicare UPIN
5L742Medicare ID - Type Unspecified