Basic Information
| Provider Information | |||||||||
| NPI: | 1538171871 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORNERSTONE EAR NOSE & THROAT PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1107 REYNOLDS ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281124351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047527575 | ||||||||
| FaxNumber: | 7047527576 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 REYNOLDS ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281124351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047527575 | ||||||||
| FaxNumber: | 7047527576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 05/14/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HELMS | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7047527575 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 890191P | 05 | NC | MEDICAID |