MEDICARE: CROSS LANES FAMILY PRACTICE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1205906625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSS LANES FAMILY PRACTICE, INC.

Provider Business Mailing Address
First Line	:	5480 BIG TYLER RD
Second Line	:
City	:	CROSS LANES
State	:	WV
Zip	:	25313-1116
Country	:	US
Telephone Number	:	304-776-2409
Fax Number	:	304-776-2023

Provider Business Practice Location Address
First Line	:	5480 BIG TYLER RD
Second Line	:
City	:	CROSS LANES
State	:	WV
Zip	:	25313-1116
Country	:	US
Telephone Number	:	304-776-2409
Fax Number	:	304-776-2023

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GREGORY C STONESTREET
Credential	:	MD
Telephone Number	:	304-776-2409

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	08/22/2020

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Directions to “CROSS LANES FAMILY PRACTICE, INC. ” Practice Location

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