Healthcare Provider Details

I. General information

NPI: 1487977369
Provider Name (Legal Business Name): STONEBRIDGE MEDICAL GROUP, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2010
Last Update Date: 03/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 STONEBRIDGE BLVD SUITE B
JACKSON TN
38305-2040
US

IV. Provider business mailing address

PO BOX 1798 DEPT. 07-100
MEMPHIS TN
38101-1798
US

V. Phone/Fax

Practice location:
  • Phone: 731-661-1008
  • Fax: 731-410-6778
Mailing address:
  • Phone: 731-661-1008
  • Fax: 731-410-6778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPN7239
License Number StateTN

VIII. Authorized Official

Name: MR. JEFFREY W YOUNG JR.
Title or Position: OWNER
Credential: FNP
Phone: 731-661-1008