Basic Information
| Provider Information | |||||||||
| NPI: | 1235474701 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORNERSTONE HEALTH CARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WARREN STACKS MD A CORNERSTONE PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 WESTCHESTER DR | ||||||||
| Address2: | SUITE 850 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272627008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022536 | ||||||||
| FaxNumber: | 3368022534 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 WESTGATE CENTER DR | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271033112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022536 | ||||||||
| FaxNumber: | 3368022534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2012 | ||||||||
| LastUpdateDate: | 05/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | TERRELL | ||||||||
| AuthorizedOfficialFirstName: | GRACE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3368022536 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1740203090 | 05 | NC | MEDICAID |