Basic Information
Provider Information | |||||||||
NPI: | 1255371274 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CORNELIUS | ||||||||
FirstName: | KATHRYN | ||||||||
MiddleName: | GOODWIN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ADAMS | ||||||||
OtherFirstName: | KATHRYN | ||||||||
OtherMiddleName: | GOODWIN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4530 SE 105TH ST | ||||||||
Address2: |   | ||||||||
City: | GALENA | ||||||||
State: | KS | ||||||||
PostalCode: | 667394103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4175290305 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1 MT CARMEL WAY | ||||||||
Address2: |   | ||||||||
City: | PITTSBURG | ||||||||
State: | KS | ||||||||
PostalCode: | 667627587 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202316100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/07/2006 | ||||||||
LastUpdateDate: | 10/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2002012667 | MO | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 04-43847 | KS | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 20008990A | 01 | OK | MEDICAID | OTHER | 204642102 | 05 | MO |   | MEDICAID | 243419306 | 05 | MO |   | MEDICAID |