Basic Information
| Provider Information | |||||||||
| NPI: | 1790759520 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TERRELL L STONE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ST MATTHEWS FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 638 | ||||||||
| Address2: | |||||||||
| City: | ST MATTHEWS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291350638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038743902 | ||||||||
| FaxNumber: | 8038743905 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 HARRY C RAYSOR DR | ||||||||
| Address2: | |||||||||
| City: | ST MATTHEWS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291358403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038743902 | ||||||||
| FaxNumber: | 8038743905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | STONE | ||||||||
| AuthorizedOfficialFirstName: | TERRELL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8038743902 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 13583 | SC | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 291U00000X | 42D0916819 | SC | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | GP0753 | 05 | SC | MEDICAID |