Provider Demographics
NPI:1265709208
Name:STONES RIVER PSYCHIATRY GROUP INC
Entity type:Organization
Organization Name:STONES RIVER PSYCHIATRY GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:VISWA
Authorized Official - Middle Name:BHARATHI
Authorized Official - Last Name:DURVASULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-372-8700
Mailing Address - Street 1:225 N WILLOW AVE
Mailing Address - Street 2:STE. 1
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2335
Mailing Address - Country:US
Mailing Address - Phone:931-372-8700
Mailing Address - Fax:931-372-8717
Practice Address - Street 1:225 N WILLOW AVE
Practice Address - Street 2:STE. 1
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2335
Practice Address - Country:US
Practice Address - Phone:931-372-8700
Practice Address - Fax:931-372-8717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD200372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNG75880Medicare UPIN