Provider Demographics
NPI:1114180619
Name:SMG LAB PLLC IDTF
Entity Type:Organization
Organization Name:SMG LAB PLLC IDTF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALTON
Authorized Official - Middle Name:SID
Authorized Official - Last Name:KING
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:615-230-8070
Mailing Address - Street 1:300 STEAM PLANT RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-3032
Mailing Address - Country:US
Mailing Address - Phone:615-230-8070
Mailing Address - Fax:615-452-1774
Practice Address - Street 1:575 E BLEDSOE ST
Practice Address - Street 2:SUITE 7
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066-3054
Practice Address - Country:US
Practice Address - Phone:615-452-2511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMNER MEDICAL GROUP PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000544291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
3790344Medicare PIN