Provider Demographics
NPI:1114956091
Name:CORNERSTONE CLINIC, LTD.
Entity Type:Organization
Organization Name:CORNERSTONE CLINIC, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JODI
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOLBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-484-6300
Mailing Address - Street 1:PO BOX 5287
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61125-0287
Mailing Address - Country:US
Mailing Address - Phone:815-484-6300
Mailing Address - Fax:815-395-2021
Practice Address - Street 1:1235 N MULFORD RD STE 210
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3879
Practice Address - Country:US
Practice Address - Phone:815-484-6300
Practice Address - Fax:815-395-2021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084288207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
591450Medicare ID - Type Unspecified