Provider Demographics
NPI:1659439396
Name:MEDICAL GROUP STONECREST PULMONOLOGY LLC
Entity Type:Organization
Organization Name:MEDICAL GROUP STONECREST PULMONOLOGY LLC
Other - Org Name:STONECREST GATEWAY PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:RYDBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7415
Mailing Address - Street 1:1725 MEDICAL CENTER PKWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-2246
Mailing Address - Country:US
Mailing Address - Phone:615-494-3939
Mailing Address - Fax:615-494-3941
Practice Address - Street 1:1725 MEDICAL CENTER PKWY
Practice Address - Street 2:SUITE 130
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-2246
Practice Address - Country:US
Practice Address - Phone:615-494-3939
Practice Address - Fax:615-494-3941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3735729Medicaid
TN3735729Medicare PIN
DF5267Medicare PIN