Provider Demographics
NPI:1255371274
Name:CORNELIUS, KATHRYN GOODWIN (MD)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:GOODWIN
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:GOODWIN
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4530 SE 105TH ST
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:KS
Mailing Address - Zip Code:66739-4103
Mailing Address - Country:US
Mailing Address - Phone:417-529-0305
Mailing Address - Fax:
Practice Address - Street 1:1 MT CARMEL WAY
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-7587
Practice Address - Country:US
Practice Address - Phone:620-231-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002012667207P00000X
KS04-43847207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK20008990AOtherMEDICAID
MO204642102Medicaid
MO243419306Medicaid
MO243419306Medicaid
MO204642102Medicaid