Healthcare Provider Details

I. General information

NPI: 1457809402
Provider Name (Legal Business Name): CORNERSTONE MEDICAL AND SURGICAL ASSOCIATES L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 BEY LEA RD SUITE 3
TOMS RIVER NJ
08753-2978
US

IV. Provider business mailing address

54 BEY LEA RD SUITE 3
TOMS RIVER NJ
08753-2978
US

V. Phone/Fax

Practice location:
  • Phone: 732-281-0100
  • Fax: 732-281-0400
Mailing address:
  • Phone: 732-281-0100
  • Fax: 732-281-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number25MB05659300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number25MA03236800
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number25MA08847700
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number25MA0832810
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number25MA07280500
License Number StateNJ
# 6
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number25MA09358600
License Number StateNJ
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00161000
License Number StateNJ
# 8
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number25MB06567300
License Number StateNJ

VIII. Authorized Official

Name: BRUCE PETERS
Title or Position: OFFICER/MANAGER
Credential: D.O.
Phone: 732-281-0100