Provider Demographics
NPI:1871797753
Name:CORNERSTONE PEDIATRIC SURGERY, PSC
Entity type:Organization
Organization Name:CORNERSTONE PEDIATRIC SURGERY, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BEALS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-224-0801
Mailing Address - Street 1:535 WELLINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1385
Mailing Address - Country:US
Mailing Address - Phone:859-224-0801
Mailing Address - Fax:859-224-0899
Practice Address - Street 1:535 WELLINGTON WAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1385
Practice Address - Country:US
Practice Address - Phone:859-224-0801
Practice Address - Fax:859-224-0899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY359692086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000539897OtherANTHEM