Provider Demographics
NPI:1316011679
Name:STF MEDICAL & MANAGEMENT GROUP INC
Entity Type:Organization
Organization Name:STF MEDICAL & MANAGEMENT GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:OMOTAYO
Authorized Official - Last Name:OMOTUNDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-937-7641
Mailing Address - Street 1:1049 CRESTHAVEN RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3833
Mailing Address - Country:US
Mailing Address - Phone:901-761-9798
Mailing Address - Fax:901-761-9799
Practice Address - Street 1:1049 CRESTHAVEN RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3833
Practice Address - Country:US
Practice Address - Phone:901-761-9798
Practice Address - Fax:901-761-9799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TN0000000912332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1455183Medicaid
TN5884780001Medicare NSC