Provider Demographics
NPI:1215210364
Name:AMG - HILLSIDE, LLC
Entity Type:Organization
Organization Name:AMG - HILLSIDE, LLC
Other - Org Name:KIDS FIRST PEDIATRIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESS
Authorized Official - Middle Name:
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:PO BOX 631
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:TN
Mailing Address - Zip Code:38478-0631
Mailing Address - Country:US
Mailing Address - Phone:931-363-4543
Mailing Address - Fax:931-363-4523
Practice Address - Street 1:202 HILLSIDE DR
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478-4566
Practice Address - Country:US
Practice Address - Phone:931-363-4543
Practice Address - Fax:931-363-4523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO1829208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3374856Medicare PIN