Provider Demographics
NPI:1962660886
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:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESS
Authorized Official - Middle Name:N
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:1397 S COLLEGE ST
Mailing Address - Street 2:BLDG 2 SUITE 2
Mailing Address - City:WINCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37398-2414
Mailing Address - Country:US
Mailing Address - Phone:931-967-2520
Mailing Address - Fax:931-967-2518
Practice Address - Street 1:1397 S COLLEGE ST
Practice Address - Street 2:BLDG 2 SUITE 2
Practice Address - City:WINCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37398-2414
Practice Address - Country:US
Practice Address - Phone:931-967-2520
Practice Address - Fax:931-967-2518
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMG SOUTHERN TENNESSEE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-28
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN37164462Medicare PIN