Provider Demographics
NPI:1235460676
Name:CORNERSTONE MEDICAL CLINIC
Entity Type:Organization
Organization Name:CORNERSTONE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORINDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARCEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-241-3401
Mailing Address - Street 1:1420 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-1810
Mailing Address - Country:US
Mailing Address - Phone:253-987-5156
Mailing Address - Fax:253-987-5462
Practice Address - Street 1:1420 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-1810
Practice Address - Country:US
Practice Address - Phone:253-987-5156
Practice Address - Fax:253-987-5462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036169207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA98390A015OtherTRICARE
WA9869DAOtherREGENCE RIDER
WA8232878Medicaid
WA911203494BPOtherKPS
WA0185591OtherL & I
WA5496722OtherAETNA
WAG76831Medicare UPIN
WA911203494BPOtherKPS