1679851455 NPI number — CORNERSTONE PEDIATRICS, P.C.

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 1679851455 NPI number — CORNERSTONE PEDIATRICS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORNERSTONE PEDIATRICS, P.C.
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:
6
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:
1679851455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7875 E FLORENTINE RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
PRESCOTT VALLEY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86314-2284
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-443-5599
Provider Business Mailing Address Fax Number:
928-443-5376

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7875 E FLORENTINE RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PRESCOTT VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86314-2284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-443-5599
Provider Business Practice Location Address Fax Number:
928-443-5376
Provider Enumeration Date:
07/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KLEIN
Authorized Official First Name:
SHELLY
Authorized Official Middle Name:
FAY
Authorized Official Title or Position:
OWNER/MD
Authorized Official Telephone Number:
928-443-5599

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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