1932195187 NPI number — CORNERSTONE PSYCHIATRIC SERVICES INC

Table of content: (NPI 1932195187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932195187 NPI number — CORNERSTONE PSYCHIATRIC SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORNERSTONE PSYCHIATRIC SERVICES INC
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:
1932195187
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1790 E VENICE AVE
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
VENICE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34292-3191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-488-8884
Provider Business Mailing Address Fax Number:
941-488-5554

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1790 E VENICE AVE
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
VENICE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34292-3191
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-488-8884
Provider Business Practice Location Address Fax Number:
941-488-5554
Provider Enumeration Date:
09/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LABATH
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
941-488-8884

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: OS8175 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0808X , with the licence number: ARNP1799382 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 270064600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7384438 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: DA7120 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 557401-000 . This is a "MAGELLAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 270064600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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