Provider Demographics
NPI:1659322808
Name:STONECREST FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:STONECREST FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:CREQUE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:502-633-5565
Mailing Address - Street 1:101 STONECREST ROAD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065
Mailing Address - Country:US
Mailing Address - Phone:502-633-5565
Mailing Address - Fax:502-633-5154
Practice Address - Street 1:101 STONECREST ROAD
Practice Address - Street 2:SUITE 3
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065
Practice Address - Country:US
Practice Address - Phone:502-633-5565
Practice Address - Fax:502-633-5154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36516261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY=========OtherTAX INDENTIFICATION