Provider Demographics
NPI:1205689171
Name:CORNER HEALTH MEDICAL GROUP P A
Entity type:Organization
Organization Name:CORNER HEALTH MEDICAL GROUP P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAVANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-860-3441
Mailing Address - Street 1:312 ARIZONA AVE STE 314
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-1306
Mailing Address - Country:US
Mailing Address - Phone:404-860-3441
Mailing Address - Fax:
Practice Address - Street 1:2 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-2322
Practice Address - Country:US
Practice Address - Phone:602-123-4567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-09
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No251E00000XAgenciesHome Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility