Basic Information
Provider Information | |||||||||
NPI: | 1710165089 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CORNERSTONE MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ST JOHN WEIGHT LOSS INSTITUTE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 45660 SCHOENHERR RD | ||||||||
Address2: |   | ||||||||
City: | SHELBY TOWNSHIP | ||||||||
State: | MI | ||||||||
PostalCode: | 483156033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5862266843 | ||||||||
FaxNumber: | 5865663068 | ||||||||
Practice Location | |||||||||
Address1: | 43750 GARFIELD RD | ||||||||
Address2: | SUITE 104 | ||||||||
City: | CLINTON TWP | ||||||||
State: | MI | ||||||||
PostalCode: | 480381135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5862266865 | ||||||||
FaxNumber: | 5862266880 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/08/2008 | ||||||||
LastUpdateDate: | 02/08/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUNSBERGER | ||||||||
AuthorizedOfficialFirstName: | PHIL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | C.A.O. | ||||||||
AuthorizedOfficialTelephone: | 5862266937 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 932504 | MI | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | 0N55210 | 01 | MI | MEDICARE | OTHER |