Basic Information
Provider Information | |||||||||
NPI: | 1124396502 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CORNERSTONE HEALTH CARE, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CORNERSTONE SURGERY AT PREMIER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1701 WESTCHESTER DRIVE | ||||||||
Address2: | SUITE 850 | ||||||||
City: | HIGH PIONT | ||||||||
State: | NC | ||||||||
PostalCode: | 272627254 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3368022536 | ||||||||
FaxNumber: | 3368022534 | ||||||||
Practice Location | |||||||||
Address1: | 4515 PREMIER DRIVE | ||||||||
Address2: | SUITE 202 | ||||||||
City: | HIGH POINT | ||||||||
State: | NC | ||||||||
PostalCode: | 272658356 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3368022150 | ||||||||
FaxNumber: | 3368022151 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2011 | ||||||||
LastUpdateDate: | 11/15/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TERRELL | ||||||||
AuthorizedOfficialFirstName: | GRACE | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
AuthorizedOfficialTelephone: | 3368022400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.