Provider Demographics
NPI:1790759520
Name:TERRELL L STONE
Entity Type:Organization
Organization Name:TERRELL L STONE
Other - Org Name:ST MATTHEWS FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-874-3902
Mailing Address - Street 1:PO BOX 638
Mailing Address - Street 2:
Mailing Address - City:ST MATTHEWS
Mailing Address - State:SC
Mailing Address - Zip Code:29135-0638
Mailing Address - Country:US
Mailing Address - Phone:803-874-3902
Mailing Address - Fax:803-874-3905
Practice Address - Street 1:725 HARRY C RAYSOR DR
Practice Address - Street 2:
Practice Address - City:ST MATTHEWS
Practice Address - State:SC
Practice Address - Zip Code:29135-8403
Practice Address - Country:US
Practice Address - Phone:803-874-3902
Practice Address - Fax:803-874-3905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-16
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13583207Q00000X
SC42D0916819291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0753Medicaid
SC4429Medicare PIN