Healthcare Provider Details

I. General information

NPI: 1871797753
Provider Name (Legal Business Name): CORNERSTONE PEDIATRIC SURGERY, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 05/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 WELLINGTON WAY
LEXINGTON KY
40503-1385
US

IV. Provider business mailing address

535 WELLINGTON WAY
LEXINGTON KY
40503-1385
US

V. Phone/Fax

Practice location:
  • Phone: 859-224-0801
  • Fax: 859-224-0899
Mailing address:
  • Phone: 859-224-0801
  • Fax: 859-224-0899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number35969
License Number StateKY

VIII. Authorized Official

Name: DANIEL A BEALS
Title or Position: OWNER
Credential: MD
Phone: 859-224-0801