MEDICARE: CORNERSTONE PROJECT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	103T00000X	Psychologist
2	103TA0400X	Addiction (Substance Use Disorder) Psychologist
3	207Q00000X	Family Medicine Physician
4	207QA0401X	Addiction Medicine (Family Medicine) Physician
5	207RA0401X	Addiction Medicine (Internal Medicine) Physician
6	208D00000X	General Practice Physician
7	291U00000X	Clinical Medical Laboratory
8	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1417206954
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORNERSTONE PROJECT, LLC

Provider Business Mailing Address
First Line	:	4124 LINDEN AVE
Second Line	:	SUITE 100
City	:	DAYTON
State	:	OH
Zip	:	45432-3018
Country	:	US
Telephone Number	:	937-522-0961
Fax Number	:	937-522-0951

Provider Business Practice Location Address
First Line	:	4124 LINDEN AVE
Second Line	:	SUITE 100
City	:	DAYTON
State	:	OH
Zip	:	45432-3018
Country	:	US
Telephone Number	:	937-522-0961
Fax Number	:	937-522-0951

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	MR. MICHAEL WARD
Credential	:
Telephone Number	:	937-522-0961

Provider Enumeration Date	:	08/30/2012
Last Update Date	:	02/07/2018

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1639609548 — CORNERSTONE PROJECT, LLC
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45432-3018

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Practice Fax:

Directions to “CORNERSTONE PROJECT, LLC ” Practice Location

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