1013996305 NPI number — CONSTANCE C CORSINO MD INC

Table of content: (NPI 1013996305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013996305 NPI number — CONSTANCE C CORSINO MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONSTANCE C CORSINO MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHILDRENS MEDICAL GROUP OF CHINO
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013996305
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12574 CENTRAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-627-7433
Provider Business Mailing Address Fax Number:
909-627-8573

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12574 CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-627-7433
Provider Business Practice Location Address Fax Number:
909-627-8573
Provider Enumeration Date:
01/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CORSINO
Authorized Official First Name:
CONSTANCE
Authorized Official Middle Name:
CHAPPELL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
909-627-7433

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  G25276 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: E99018 . This identifiers is of the category "MEDICARE UPIN".
  • Identifier: 00G252760 , issued by the state of ( CA ) . This identifiers is of the category "MEDICARE ID-TYPE UNSPECIFIED".