Provider Demographics
NPI:1689669079
Name:CORNERSTONE FAMILY HEALTHCARE
Entity type:Organization
Organization Name:CORNERSTONE FAMILY HEALTHCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:JOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-220-3165
Mailing Address - Street 1:2570 ROUTE 9W
Mailing Address - Street 2:SUITE 10
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518-1323
Mailing Address - Country:US
Mailing Address - Phone:845-220-3100
Mailing Address - Fax:845-534-2940
Practice Address - Street 1:147 LAKE STREET
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-5242
Practice Address - Country:US
Practice Address - Phone:845-563-8000
Practice Address - Fax:845-563-8093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X
NY000425332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWCW271OtherMEDICARE ID
NY331832OtherMEDICARE ID
NY00472931Medicaid