Provider Demographics
NPI:1710165089
Name:CORNERSTONE MEDICAL GROUP
Entity Type:Organization
Organization Name:CORNERSTONE MEDICAL GROUP
Other - Org Name:ST JOHN WEIGHT LOSS INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.A.O.
Authorized Official - Prefix:
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNSBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-226-6937
Mailing Address - Street 1:45660 SCHOENHERR RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-6033
Mailing Address - Country:US
Mailing Address - Phone:586-226-6843
Mailing Address - Fax:586-566-3068
Practice Address - Street 1:43750 GARFIELD RD
Practice Address - Street 2:SUITE 104
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1135
Practice Address - Country:US
Practice Address - Phone:586-226-6865
Practice Address - Fax:586-226-6880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI932504133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N55210OtherMEDICARE