Basic Information
| Provider Information | |||||||||
| NPI: | 1851765374 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASCENSION MICHIGAN-CMG | ||||||||
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| OtherOrganizationName: | CORNERSTONE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28000 DEQUINDRE ROAD | ||||||||
| Address2: | REVENUE CYCLE DEPARTMENT | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486808000 | ||||||||
| FaxNumber: | 2482923852 | ||||||||
| Practice Location | |||||||||
| Address1: | 43900 GARFIELD RD STE 222 | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862860050 | ||||||||
| FaxNumber: | 5862860880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2015 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | ZUCKERMAN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5867531181 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | FACHE | ||||||||
| NPICertificationDate: | 06/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.