Provider Demographics
NPI:1518229327
Name:CORNERSTONE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:CORNERSTONE MEDICAL GROUP LLC
Other - Org Name:COSMOPOLITAN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GROWTH & RISK MANAGEMENT DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS-SHASHIKARSHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-597-7315
Mailing Address - Street 1:PO BOX 10508
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34603-0508
Mailing Address - Country:US
Mailing Address - Phone:352-597-7315
Mailing Address - Fax:
Practice Address - Street 1:13111 SPRING HILL DR
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-5052
Practice Address - Country:US
Practice Address - Phone:352-597-7315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty