Provider Demographics
NPI:1073539607
Name:CROSSROADS MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:CROSSROADS MEDICAL GROUP, PLLC
Other - Org Name:CROSSROADS MEDICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-672-7122
Mailing Address - Street 1:PO BOX 1669
Mailing Address - Street 2:
Mailing Address - City:WHITE HOUSE
Mailing Address - State:TN
Mailing Address - Zip Code:37188-1669
Mailing Address - Country:US
Mailing Address - Phone:615-672-5177
Mailing Address - Fax:615-672-5366
Practice Address - Street 1:491 SAGE RD.
Practice Address - Street 2:SUITE 200
Practice Address - City:WHITE HOUSE
Practice Address - State:TN
Practice Address - Zip Code:37188-8193
Practice Address - Country:US
Practice Address - Phone:615-672-7122
Practice Address - Fax:615-672-8122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3725461Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER