Basic Information
| Provider Information | |||||||||
| NPI: | 1225018864 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORNELIUS | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636256 CENTRAL CREDENTIALING | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132453107 | ||||||||
| FaxNumber: | 5135855511 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 THOMAS MORE PKWY | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410175465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132211100 | ||||||||
| FaxNumber: | 5135695297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 02/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35.059824 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 35381 | KY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 138300001 | 01 | OH | CARESOURCE | OTHER | 64864200 | 05 | KY | MEDICAID | 0786645 | 05 | OH | MEDICAID | 300033820 | 01 | OH | RAILROAD MEDICARE | OTHER | 655253 | 01 | OH | AETNA | OTHER | 1620959 | 01 | OH | UNITED HEALTHCARE | OTHER | 000000014204 | 01 | OH | ANTHEM | OTHER | 200039490A | 05 | IN | MEDICAID |