Provider Demographics
NPI:1710917760
Name:CROSSROADS FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:CROSSROADS FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-202-1703
Mailing Address - Street 1:950 BAKER HWY
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37756-4168
Mailing Address - Country:US
Mailing Address - Phone:404-266-9876
Mailing Address - Fax:404-266-2669
Practice Address - Street 1:950 BAKER HWY
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37756-4168
Practice Address - Country:US
Practice Address - Phone:404-266-9876
Practice Address - Fax:404-266-2669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000038388207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I29645Medicare UPIN