1316971237 NPI number — CORNERSTONE SURGICAL PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316971237 NPI number — CORNERSTONE SURGICAL PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORNERSTONE SURGICAL 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:
Provider Other Organization Name Type Code:
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:
1316971237
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 917
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLNTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28093
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-735-7069
Provider Business Mailing Address Fax Number:
704-735-7537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
206 GAMBLE DRIVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LINCOLNTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-735-7069
Provider Business Practice Location Address Fax Number:
704-735-7537
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUCKLEN
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
704-735-7069

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5901768 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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