Healthcare Provider Details

I. General information

NPI: 1598325151
Provider Name (Legal Business Name): CORNERSTONE PEDIATRICS AND FAMILY ALLERGY, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 LAKE DRIVE #260
WEST DES MONIES IA
50266
US

IV. Provider business mailing address

6800 LAKE DRIVE #260
WEST DES MONIES IA
50266
US

V. Phone/Fax

Practice location:
  • Phone: 515-822-3192
  • Fax:
Mailing address:
  • Phone: 515-822-3192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TARA J FEDERLY
Title or Position: OWNER/PHYSICIAN
Credential:
Phone: 952-546-6866