Basic Information
Provider Information | |||||||||
NPI: | 1043264278 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CORNERSTONE HOSPITAL OF SOUTHEAST ARIZONA LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CORNERSTONE HOSPITAL OF SOUTHEAST ARIZONA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2200 ROSS AVE | ||||||||
Address2: | SUITE 5400 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752017918 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4696216700 | ||||||||
FaxNumber: | 4696216672 | ||||||||
Practice Location | |||||||||
Address1: | 7220 E ROSEWOOD ST | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857101350 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5205464595 | ||||||||
FaxNumber: | 5202901465 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2006 | ||||||||
LastUpdateDate: | 06/24/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUDSON | ||||||||
AuthorizedOfficialFirstName: | LYNN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CENTRAL BUSINESS OFFICE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4696216716 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | SH-3843 | AZ | Y |   | Hospitals | Long Term Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 004042 | 05 | AZ |   | MEDICAID |