Provider Demographics
NPI:1316971237
Name:CORNERSTONE SURGICAL PA
Entity type:Organization
Organization Name:CORNERSTONE SURGICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:R
Authorized Official - Last Name:BUCKLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:704-735-7069
Mailing Address - Street 1:PO BOX 917
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28093
Mailing Address - Country:US
Mailing Address - Phone:704-735-7069
Mailing Address - Fax:704-735-7537
Practice Address - Street 1:206 GAMBLE DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092
Practice Address - Country:US
Practice Address - Phone:704-735-7069
Practice Address - Fax:704-735-7537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901768Medicaid
NC2348555Medicare ID - Type Unspecified
B91520Medicare UPIN