Basic Information
| Provider Information | |||||||||
| NPI: | 1003939216 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORNING MEDICAL ASSOCIATES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 SOLANO ST | ||||||||
| Address2: | |||||||||
| City: | CORNING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960213511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308244663 | ||||||||
| FaxNumber: | 5308245204 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 SOLANO ST | ||||||||
| Address2: | |||||||||
| City: | CORNING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960213511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308244663 | ||||||||
| FaxNumber: | 5308245204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MASSIE | ||||||||
| AuthorizedOfficialFirstName: | DON | ||||||||
| AuthorizedOfficialMiddleName: | CARL | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5308244663 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PA-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | BCP03910G | 05 | CA | MEDICAID |