MEDICARE: STONE CREEK FAMILY MEDICINE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1467779454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STONE CREEK FAMILY MEDICINE PLLC

Provider Business Mailing Address
First Line	:	19782 HIGHWAY 105 W
Second Line	:	SUITE 111
City	:	MONTGOMERY
State	:	TX
Zip	:	77356-3103
Country	:	US
Telephone Number	:	936-582-0220
Fax Number	:	936-582-0222

Provider Business Practice Location Address
First Line	:	19782 HIGHWAY 105 W
Second Line	:	SUITE 111
City	:	MONTGOMERY
State	:	TX
Zip	:	77356-3103
Country	:	US
Telephone Number	:	936-582-0220
Fax Number	:	936-582-0222

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JENNIFER L CHILEK
Credential	:	MD
Telephone Number	:	936-718-3034

Provider Enumeration Date	:	04/29/2010
Last Update Date	:	04/29/2010

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