MEDICARE: CORNERSTONE FAMILY HEALTHCARE

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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1831712629
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORNERSTONE FAMILY HEALTHCARE

Provider Business Mailing Address
First Line	:	2570 ROUTE 9W STE 10
Second Line	:
City	:	CORNWALL
State	:	NY
Zip	:	12518-1370
Country	:	US
Telephone Number	:	845-220-3100
Fax Number	:	845-534-2940

Provider Business Practice Location Address
First Line	:	140 HAMMOND ST
Second Line	:
City	:	PORT JERVIS
State	:	NY
Zip	:	12771-2607
Country	:	US
Telephone Number	:	845-563-8000
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DAVID JOLLY
Credential	:
Telephone Number	:	845-220-3165

Provider Enumeration Date	:	05/27/2020
Last Update Date	:	01/10/2023

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