Provider Demographics
NPI:1205167509
Name:ADVANCED MEDICAL GROUP
Entity type:Organization
Organization Name:ADVANCED MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAGG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:865-982-7802
Mailing Address - Street 1:615 LEEPER PKWY
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-6151
Mailing Address - Country:US
Mailing Address - Phone:865-986-8600
Mailing Address - Fax:865-986-0961
Practice Address - Street 1:717 WATKINS RD
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-4598
Practice Address - Country:US
Practice Address - Phone:865-980-7802
Practice Address - Fax:865-980-7804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000011720363LA2200X
TN0000013567363LA2200X
TN0682208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1510839Medicaid
TN3724930Medicare PIN