Provider Demographics
NPI:1639152739
Name:CORNERSTONE PROFESSIONAL ASSOCIATES
Entity Type:Organization
Organization Name:CORNERSTONE PROFESSIONAL ASSOCIATES
Other - Org Name:HAYDEN LAKE FAMILY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:P
Authorized Official - Last Name:BORSHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-772-0785
Mailing Address - Street 1:8181 CORNERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835
Mailing Address - Country:US
Mailing Address - Phone:208-772-0785
Mailing Address - Fax:208-762-2704
Practice Address - Street 1:8181 CORNERSTONE DR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835
Practice Address - Country:US
Practice Address - Phone:208-772-0785
Practice Address - Fax:208-762-2704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805031100Medicaid
ID4986080001Medicare NSC
ID1374956Medicare ID - Type Unspecified