1720103609 NPI number — CORNERSTONE HEALTH CARE PA

Table of content: (NPI 1720103609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720103609 NPI number — CORNERSTONE HEALTH CARE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORNERSTONE HEALTH CARE PA
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:
CORNERSTONE CONVENIENCE CARE CLINIC AT PREMIER
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:
1720103609
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 WESTCHESTER DRIVE
Provider Second Line Business Mailing Address:
SUITE 850
Provider Business Mailing Address City Name:
HIGH POINT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27262-7254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-802-2536
Provider Business Mailing Address Fax Number:
336-802-2534

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4515 PREMIER DRIVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
HIGH POINT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27265-8350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-802-2222
Provider Business Practice Location Address Fax Number:
336-802-2351
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TERRELL
Authorized Official First Name:
GRACE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT / CEO
Authorized Official Telephone Number:
336-802-2400

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 890281L , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: CB8658 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: D266 . This is a "PARTNERS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 25864 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0281L . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7030772 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CC4243 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CC4241 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CD6614 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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