Basic Information
| Provider Information | |||||||||
| NPI: | 1508935065 | ||||||||
| 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: | 11/07/2006 | ||||||||
| LastUpdateDate: | 08/24/2010 | ||||||||
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| AuthorizedOfficialLastName: | MASSIE | ||||||||
| AuthorizedOfficialFirstName: | CONNIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5308244663 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS21280 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207Q00000X | 20A8205 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | A83711 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363AM0700X | PA10063 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA12619 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA10631 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA12458 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 207Q00000X | A21329 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0026340 | 05 | CA | MEDICAID |