Provider Demographics
NPI:1275515967
Name:CORNERSTONE MEDICAL GROUP
Entity type:Organization
Organization Name:CORNERSTONE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-226-3139
Mailing Address - Street 1:914 VISTA DRIVE
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30721-8654
Mailing Address - Country:US
Mailing Address - Phone:706-226-3139
Mailing Address - Fax:706-278-6606
Practice Address - Street 1:914 VISTA DRIVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-8654
Practice Address - Country:US
Practice Address - Phone:706-226-3139
Practice Address - Fax:706-278-6606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAR98877Medicare UPIN
GAH04273Medicare UPIN
GAD31264Medicare UPIN
GAD39425Medicare UPIN
GAH04272Medicare UPIN
GAF42126Medicare UPIN
GAG54823Medicare UPIN