1831606243 NPI number — MRS. MARIAH GABRIELLE CORNING MSOTR/L

Table of content: MRS. MARIAH GABRIELLE CORNING MSOTR/L (NPI 1831606243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831606243 NPI number — MRS. MARIAH GABRIELLE CORNING MSOTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORNING
Provider First Name:
MARIAH
Provider Middle Name:
GABRIELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSOTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOWERS
Provider Other First Name:
MARIAH
Provider Other Middle Name:
GABRIELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1831606243
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7740 ROCK RIVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INTERLAKEN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-279-7319
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 W BUFFALO ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ITHACA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-247-2209
Provider Business Practice Location Address Fax Number:
607-758-5271
Provider Enumeration Date:
01/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  022207 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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