MEDICARE: CORNERSTONE FAMILY MEDICINE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1376257832
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORNERSTONE FAMILY MEDICINE PLLC

Provider Business Mailing Address
First Line	:	3100 DOWNS AVE
Second Line	:
City	:	WOODWARD
State	:	OK
Zip	:	73801-5328
Country	:	US
Telephone Number	:	580-254-5316
Fax Number	:	580-254-0130

Provider Business Practice Location Address
First Line	:	4902 OKLAHOMA AVE
Second Line	:
City	:	WOODWARD
State	:	OK
Zip	:	73801-3713
Country	:	US
Telephone Number	:	580-254-5316
Fax Number	:	580-254-0130

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	KEENAN FERGUSON
Credential	:	DO
Telephone Number	:	580-254-5316

Provider Enumeration Date	:	01/10/2023
Last Update Date	:	01/10/2023

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