Provider Demographics
NPI:1154373512
Name:AMG -SOUTHERN TENNESSEE LLC
Entity type:Organization
Organization Name:AMG -SOUTHERN TENNESSEE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GRACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:155 HOSPITAL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WINCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37398-2494
Mailing Address - Country:US
Mailing Address - Phone:931-962-4040
Mailing Address - Fax:931-962-2277
Practice Address - Street 1:155 HOSPITAL RD
Practice Address - Street 2:SUITE B
Practice Address - City:WINCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37398-2494
Practice Address - Country:US
Practice Address - Phone:931-962-4040
Practice Address - Fax:931-962-2277
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMG- SOUTHERN TENNESSEE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-16
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3716446Medicaid
TN3716446Medicare PIN