1366870362 NPI number — CORNERSTONE GENERAL SURGERY CLINIC INC

Table of content: (NPI 1366870362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366870362 NPI number — CORNERSTONE GENERAL SURGERY CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORNERSTONE GENERAL SURGERY CLINIC 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:
1366870362
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14149
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70898-4149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-930-0060
Provider Business Mailing Address Fax Number:
225-952-9075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1939 PATTERSON ST STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GUNTERSVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35976-2017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-930-0060
Provider Business Practice Location Address Fax Number:
225-952-9075
Provider Enumeration Date:
10/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MONK
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
225-930-0060

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  26404 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 154531 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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