Healthcare Provider Details

I. General information

NPI: 1275575888
Provider Name (Legal Business Name): CORNERSTONE MEDICAL ASSOC., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 04/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 KEITH DR
PERRY GA
31069-2947
US

IV. Provider business mailing address

1024 KEITH DR
PERRY GA
31069-2947
US

V. Phone/Fax

Practice location:
  • Phone: 478-987-3445
  • Fax: 478-987-3102
Mailing address:
  • Phone: 478-987-3445
  • Fax: 478-987-3102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number027123
License Number StateGA

VIII. Authorized Official

Name: LARRY D. STEWART JR.
Title or Position: PHYSICIAN
Credential: MD
Phone: 478-987-3445