Provider Demographics
NPI:1558413435
Name:CAVINESS, CORNELL (PA C)
Entity type:Individual
Prefix:
First Name:CORNELL
Middle Name:
Last Name:CAVINESS
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 N FRASER ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-2848
Mailing Address - Country:US
Mailing Address - Phone:843-527-3588
Mailing Address - Fax:
Practice Address - Street 1:1075 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-2848
Practice Address - Country:US
Practice Address - Phone:843-527-3588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA342207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1371Medicaid
SCRHC168Medicaid
SCGP1371Medicaid