Healthcare Provider Details

I. General information

NPI: 1306097894
Provider Name (Legal Business Name): STONE RIDGE MEDICAL GROUP SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 46TH AVE
EAST MOLINE IL
61244-4281
US

IV. Provider business mailing address

306 46TH AVE
EAST MOLINE IL
61244-4281
US

V. Phone/Fax

Practice location:
  • Phone: 309-796-2329
  • Fax: 309-796-1146
Mailing address:
  • Phone: 309-796-2329
  • Fax: 309-796-1146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085002304
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209000908
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036091695
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number336053231
License Number StateIL

VIII. Authorized Official

Name: JAMES PETRE
Title or Position: PRESIDENT
Credential: MD
Phone: 309-796-2329