Basic Information
| Provider Information | |||||||||
| NPI: | 1306097894 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STONE RIDGE MEDICAL GROUP SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 306 46TH AVE | ||||||||
| Address2: | |||||||||
| City: | EAST MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612444281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097962329 | ||||||||
| FaxNumber: | 3097961146 | ||||||||
| Practice Location | |||||||||
| Address1: | 306 46TH AVE | ||||||||
| Address2: | |||||||||
| City: | EAST MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612444281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097962329 | ||||||||
| FaxNumber: | 3097961146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2008 | ||||||||
| LastUpdateDate: | 10/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | PETRE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3097962329 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036091695 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363AM0700X | 085002304 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X | 209000908 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | 336053231 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.