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General NPI Number Information
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NPI Number | 1659322808
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Entity Type | Organization
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Legal Business Name | STONECREST FAMILY MEDICINE PLLC
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Dates
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Enumeration Date | 05/12/2006
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Last Update Date | 08/20/2014
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Provider Practice Location Address
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Address Line | 101 STONECREST ROAD SUITE 3
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City | SHELBYVILLE
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State | KY
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Zip | 40065
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Country | US
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Telephone | 502-633-5565
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Fax | 502-633-5154
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Provider Business Mailing Address
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Address Line | 101 STONECREST ROAD SUITE 3
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City | SHELBYVILLE
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State | KY
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Zip | 40065
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Country | US
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Telephone | 502-633-5565
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Fax | 502-633-5154
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Authorized Official
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Title or Position | OWNER
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Name | RONALD E CREQUE JR.
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Credential | MD
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Telephone | 502-633-5565
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 36516
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License Number State | KY
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