Basic Information
| Provider Information | |||||||||
| NPI: | 1720103609 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORNERSTONE HEALTH CARE PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CORNERSTONE CONVENIENCE CARE CLINIC AT PREMIER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 WESTCHESTER DRIVE | ||||||||
| Address2: | SUITE 850 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272627254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022536 | ||||||||
| FaxNumber: | 3368022534 | ||||||||
| Practice Location | |||||||||
| Address1: | 4515 PREMIER DRIVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272658350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022222 | ||||||||
| FaxNumber: | 3368022351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 11/03/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TERRELL | ||||||||
| AuthorizedOfficialFirstName: | GRACE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
| AuthorizedOfficialTelephone: | 3368022400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 890281L | 05 | NC | MEDICAID | CB8658 | 01 | NC | RR MEDICARE | OTHER | D266 | 01 | NC | PARTNERS | OTHER | 25864 | 01 | NC | MEDCOST | OTHER | 0281L | 01 | NC | BCBS | OTHER | 7030772 | 01 | NC | AETNA | OTHER | CC4243 | 01 | NC | RR MEDICARE | OTHER | CC4241 | 01 | NC | RR MEDICARE | OTHER | CD6614 | 01 | NC | RR MEDICARE | OTHER |