Provider Demographics
NPI:1619903895
Name:STONES RIVER PSYCHIATRIC GROUP PC
Entity Type:Organization
Organization Name:STONES RIVER PSYCHIATRIC GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHIPRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PUTATUNDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-893-8755
Mailing Address - Street 1:1024 N HIGHLAND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37130-2443
Mailing Address - Country:US
Mailing Address - Phone:615-893-8755
Mailing Address - Fax:615-893-8732
Practice Address - Street 1:1024 N HIGHLAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-2443
Practice Address - Country:US
Practice Address - Phone:615-893-8755
Practice Address - Fax:615-893-8732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000257862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3065691OtherBCBS
TN3088135Medicaid
TN3088135Medicare PIN
TN3065691OtherBCBS