Provider Demographics
NPI:1376664540
Name:JR MEDICAL GROUP, PLC
Entity Type:Organization
Organization Name:JR MEDICAL GROUP, PLC
Other - Org Name:CORNERSTONE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:DICK
Authorized Official - Last Name:WILLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-981-6100
Mailing Address - Street 1:4545 E SOUTHERN AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206
Mailing Address - Country:US
Mailing Address - Phone:480-981-6100
Mailing Address - Fax:480-981-5501
Practice Address - Street 1:4545 E SOUTHERN AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206
Practice Address - Country:US
Practice Address - Phone:480-981-6100
Practice Address - Fax:480-981-5501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ489254Medicaid
AZ080179242OtherRAILROAD MEDICARE PROVIDER #
AZ080181881OtherRAILROAD MEDICARE PROVIDER ID #
AZ411863Medicaid
AZ482323Medicaid
AZZ67205Medicare PIN
AZZ67204Medicare PIN
AZH11272Medicare UPIN
AZ080181881OtherRAILROAD MEDICARE PROVIDER ID #
AZ411863Medicaid