Basic Information
| Provider Information | |||||||||
| NPI: | 1780810259 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORNERSTONE PAIN MANAGEMENT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CORNERSTONE PAIN MANAGEMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 837 | ||||||||
| Address2: | |||||||||
| City: | HOWE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754590837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174199108 | ||||||||
| FaxNumber: | 8174193336 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 N. RITA LN | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174199108 | ||||||||
| FaxNumber: | 8174193336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2009 | ||||||||
| LastUpdateDate: | 09/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | SARDAR | ||||||||
| AuthorizedOfficialFirstName: | WINFRED | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 8174199108 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | L6619 | TX | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | L6619 | TX | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 210824301 | 05 | TX | MEDICAID |