1487977369 NPI number — STONEBRIDGE MEDICAL GROUP, PLC

Table of content: (NPI 1487977369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487977369 NPI number — STONEBRIDGE MEDICAL GROUP, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STONEBRIDGE MEDICAL GROUP, PLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487977369
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1798
Provider Second Line Business Mailing Address:
DEPT. 07-100
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38101-1798
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-661-1008
Provider Business Mailing Address Fax Number:
731-410-6778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 STONEBRIDGE BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38305-2040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-661-1008
Provider Business Practice Location Address Fax Number:
731-410-6778
Provider Enumeration Date:
03/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
731-661-1008

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  APN7239 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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