Basic Information
Provider Information | |||||||||
NPI: | 1073038659 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CORNERSTONES THERAPEUTIC SERVICES PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7360 N LINCOLN AVE STE 110 | ||||||||
Address2: |   | ||||||||
City: | LINCOLNWOOD | ||||||||
State: | IL | ||||||||
PostalCode: | 607121705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8479721824 | ||||||||
FaxNumber: | 8479838438 | ||||||||
Practice Location | |||||||||
Address1: | 7360 N LINCOLN AVE STE 110 | ||||||||
Address2: |   | ||||||||
City: | LINCOLNWOOD | ||||||||
State: | IL | ||||||||
PostalCode: | 607121705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8479721824 | ||||||||
FaxNumber: | 8479838438 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2017 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SMITH | ||||||||
AuthorizedOfficialFirstName: | TONYA | ||||||||
AuthorizedOfficialMiddleName: | SUE | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS OPERATIONS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8479721824 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 036-077054 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | PENDING | 01 |   | PENDING | OTHER |