Provider Demographics
NPI:1386977429
Name:STAR MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:STAR MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:GARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-459-5500
Mailing Address - Street 1:PO BOX 266
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-0266
Mailing Address - Country:US
Mailing Address - Phone:615-459-5500
Mailing Address - Fax:615-459-5032
Practice Address - Street 1:429 NISSAN DR
Practice Address - Street 2:SUITE 103
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-4366
Practice Address - Country:US
Practice Address - Phone:615-459-5500
Practice Address - Fax:615-459-5541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-08
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD17270207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1679521058OtherNPI INDIVIDUAL