Provider Demographics
NPI:1073612578
Name:AMG-SOUTHERN TENNESSEE LLC
Entity Type:Organization
Organization Name:AMG-SOUTHERN TENNESSEE LLC
Other - Org Name:IAN S. TAYLOR, MD
Other - Org Type:Doing Business As
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 1:10054 OLD TULLAHOMA RD
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-6122
Mailing Address - Country:US
Mailing Address - Phone:931-455-6688
Mailing Address - Fax:931-455-0892
Practice Address - Street 1:10054 OLD TULLAHOMA RD
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-6122
Practice Address - Country:US
Practice Address - Phone:931-455-6688
Practice Address - Fax:931-455-0892
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMG-SOUTHERN TENNESSEE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-21
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3716445Medicaid
TN=========OtherTAX ID
TN=========OtherTAX ID