Healthcare Provider Details

I. General information

NPI: 1073539607
Provider Name (Legal Business Name): CROSSROADS MEDICAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 SAGE RD. SUITE 200
WHITE HOUSE TN
37188-8193
US

IV. Provider business mailing address

PO BOX 1669
WHITE HOUSE TN
37188-1669
US

V. Phone/Fax

Practice location:
  • Phone: 615-672-7122
  • Fax: 615-672-8122
Mailing address:
  • Phone: 615-672-5177
  • Fax: 615-672-5366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT E. FERGUSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 615-672-7122