Healthcare Provider Details

I. General information

NPI: 1710917760
Provider Name (Legal Business Name): CROSSROADS FAMILY MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 BAKER HWY
HUNTSVILLE TN
37756-4168
US

IV. Provider business mailing address

950 BAKER HWY
HUNTSVILLE TN
37756-4168
US

V. Phone/Fax

Practice location:
  • Phone: 404-266-9876
  • Fax: 404-266-2669
Mailing address:
  • Phone: 404-266-9876
  • Fax: 404-266-2669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD0000038388
License Number StateTN

VIII. Authorized Official

Name: ROBERT J KELLETT
Title or Position: OWNER
Credential: M.D.
Phone: 423-202-1703