Healthcare Provider Details

I. General information

NPI: 1275515967
Provider Name (Legal Business Name): CORNERSTONE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 08/19/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 VISTA DRIVE
DALTON GA
30721-8654
US

IV. Provider business mailing address

914 VISTA DRIVE
DALTON GA
30721-8654
US

V. Phone/Fax

Practice location:
  • Phone: 706-226-3139
  • Fax: 706-278-6606
Mailing address:
  • Phone: 706-226-3139
  • Fax: 706-278-6606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ERIC JENSEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 706-226-3139