Provider Demographics
NPI:1982202263
Name:STONEHAVEN MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:STONEHAVEN MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:HAMBY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:432-219-9200
Mailing Address - Street 1:4416 BRIARWOOD AVE # 110-87
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-2615
Mailing Address - Country:US
Mailing Address - Phone:432-219-9200
Mailing Address - Fax:432-218-7879
Practice Address - Street 1:4519 N GARFIELD ST STE 1
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-3400
Practice Address - Country:US
Practice Address - Phone:432-219-9200
Practice Address - Fax:432-218-7879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-09
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP7455OtherTX MEDICAL LICENSE