Provider Demographics
NPI:1639376353
Name:STONECREST MEDICAL GROUP - FAMILY PRACTICE OF MURFREESBORO LLC
Entity Type:Organization
Organization Name:STONECREST MEDICAL GROUP - FAMILY PRACTICE OF MURFREESBORO LLC
Other - Org Name:MIDSTATE FAMILY MEDICINE AND URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7604
Mailing Address - Street 1:2706 OLD FORT PARKWAY
Mailing Address - Street 2:SUITE E
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37128
Mailing Address - Country:US
Mailing Address - Phone:615-893-1230
Mailing Address - Fax:615-893-1232
Practice Address - Street 1:2706 OLD FORT PARKWAY
Practice Address - Street 2:SUITE E
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37128
Practice Address - Country:US
Practice Address - Phone:615-893-1230
Practice Address - Fax:615-893-1232
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTHSERV ACQUISITION LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-27
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3370137Medicaid
TN3370137Medicaid