NPIMap

Organization Active NPI

Stone Ridge Medical Group SC

  • Family Medicine Physician
  • East Moline, IL
National Provider Identifier
1306097894
Registry record updated Oct 2, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
336053231 Issued in IL
Legal business name
STONE RIDGE MEDICAL GROUP SC
Practice address
306 46TH Ave
East Moline, IL 61244-4281
Phone
(309) 796-2329
Fax
(309) 796-1146
NPI assigned
Oct 2, 2008
Last updated
Oct 2, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 2, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
James Petre, MDNPI 1619973989
Title
President
Phone
(309) 796-2329

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Physician Assistant 363AM0700X 085002304 IL
Nurse Practitioner 363L00000X 209000908 IL
Family Medicine Physician 207Q00000X 036091695 IL
Family Medicine Physician 207Q00000X 336053231 IL Primary

Addresses

Primary practice location

306 46TH Ave
East Moline, IL 61244-4281

Mailing address

306 46TH Ave
East Moline, IL 61244-4281
Phone (309) 796-2329

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090122000564 IL Part B Supplier - Clinic/Group Practice 8729142534 Receives reassigned benefits from 9 practitioners
Practice locations: East Moline, IL

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
14D0946584Stone Ridge Medical Group306 46TH Ave, East Moline, IL 61244Provider-performed microscopyMay 27, 2028

National Provider Directory

National Provider Directory

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/CAIFAA

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1222905600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1222905600000",
    "number": "1306097894",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "306 46TH AVE",
            "city": "EAST MOLINE",
            "state": "IL",
            "postal_code": "612444281",
            "telephone_number": "309-796-2329",
            "fax_number": "309-796-1146"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "306 46TH AVE",
            "city": "EAST MOLINE",
            "state": "IL",
            "postal_code": "612444281",
            "telephone_number": "309-796-2329",
            "fax_number": "309-796-1146"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STONE RIDGE MEDICAL GROUP SC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-10-02",
        "last_updated": "2008-10-02",
        "status": "A",
        "authorized_official_last_name": "PETRE",
        "authorized_official_first_name": "JAMES",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "309-796-2329",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "IL",
            "license": "085002304",
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "IL",
            "license": "209000908",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IL",
            "license": "036091695",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IL",
            "license": "336053231",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in East Moline, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 2, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.