Provider Demographics
NPI:1013374073
Name:AMG CROCKETT LLC
Entity Type:Organization
Organization Name:AMG CROCKETT LLC
Other - Org Name:SOUTHERN TENNESSEE HEART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MARKET MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-766-4574
Mailing Address - Street 1:1611 S LOCUST AVE
Mailing Address - Street 2:SUITE 200B
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38464-4055
Mailing Address - Country:US
Mailing Address - Phone:931-766-3684
Mailing Address - Fax:
Practice Address - Street 1:1611 S LOCUST AVE
Practice Address - Street 2:SUITE 200B
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-4055
Practice Address - Country:US
Practice Address - Phone:931-766-3684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty