Basic Information
| Provider Information | |||||||||
| NPI: | 1992911127 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TERRELL L STONE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ST MATTHEWS FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 638 | ||||||||
| Address2: | 725 HARRY C RAYSOR DRIVE | ||||||||
| 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: | 05/15/2007 | ||||||||
| LastUpdateDate: | 07/24/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STONE | ||||||||
| AuthorizedOfficialFirstName: | TERRELL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8038743902 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 13583 | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | RHC076 | 05 | SC | MEDICAID |