Provider Demographics
NPI:1093926404
Name:AMG-SOUTHERN TENNESSEE LLC
Entity Type:Organization
Organization Name:AMG-SOUTHERN TENNESSEE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GRACECY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:83 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37398-2401
Mailing Address - Country:US
Mailing Address - Phone:931-967-3966
Mailing Address - Fax:931-962-0373
Practice Address - Street 1:83 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37398-2401
Practice Address - Country:US
Practice Address - Phone:931-967-3966
Practice Address - Fax:931-962-0373
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMG-SOUTHERN TENNESSEE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-25
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID
TN37164461Medicare PIN