Provider Demographics
NPI:1699792390
Name:AMG -SOUTHERN TENNESSEE LLC
Entity type:Organization
Organization Name:AMG -SOUTHERN TENNESSEE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
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 1:15 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEAGLE
Mailing Address - State:TN
Mailing Address - Zip Code:37356-3074
Mailing Address - Country:US
Mailing Address - Phone:931-924-4045
Mailing Address - Fax:931-924-4105
Practice Address - Street 1:15 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MONTEAGLE
Practice Address - State:TN
Practice Address - Zip Code:37356-3074
Practice Address - Country:US
Practice Address - Phone:931-924-4045
Practice Address - Fax:931-924-4105
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMG-SOUTHERN TENNESSEE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-17
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3716448Medicaid
TN3716448Medicaid
TN3716448Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER