Provider Demographics
NPI:1619103579
Name:LAWRENCEBURG FAMILY PRACTICE ASSOCIATES, PC
Entity Type:Organization
Organization Name:LAWRENCEBURG FAMILY PRACTICE ASSOCIATES, PC
Other - Org Name:HOMER L. STALEY, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOMER
Authorized Official - Middle Name:L
Authorized Official - Last Name:STALEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-762-6476
Mailing Address - Street 1:104 N LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38464-3734
Mailing Address - Country:US
Mailing Address - Phone:931-762-6476
Mailing Address - Fax:931-762-1841
Practice Address - Street 1:104 N LOCUST AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-3734
Practice Address - Country:US
Practice Address - Phone:931-762-6476
Practice Address - Fax:931-762-1841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD008952207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3170118Medicaid
1609886936Medicare PIN
TNB03386Medicare UPIN